THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: November 21, 2013 09:30 AM Thursday; Rod Welch

VA meeting SF Medical Center consult clinical trial cholesterol.

1...Summary/Objective
2...Hyperlipidemia Not Controlled Cholesterol Elevated Despite Exercise
3...Cholesterol Elevated Despite Exercise Discuss Clinical Trial
4...Clinical Trial Considered Lower Cholesterol Without Statin Drugs
5...Atorvastatin 4-week Trial Predicate Clinical Trial Add Zetia 10 MG
6...Chia Seeds Lower Cholesterol Control Weight Increase Energy
............How Chia Seeds Can Benefit Your Health
............6.Great Reasons to Start Eating Chia Seed
7...Medical Chart Progress Notes Meeting 131121 VA SF Medical Center


..............
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CONTACTS 

SUBJECTS
VA Prescribe Atorvastin 10 MG Trial 4 Weeks Evaluate Side Effects In                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
4903 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4903 -    ..
4904 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
4905 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
490501 - Follow up ref SDS 39 0000. ref SDS 38 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
490502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
490503 - Meeting to review clinical trials for lowering cholesterol.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
490504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
490505 -            [On 131125 0005 research found dizziness less common side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
490506 -            effect taking ezetimibe (zetia). ref SDS 44 JO6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
490507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
490508 -            [On 140430 0900 letter to VA notifies some minor dizziness                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
490509 -            has begun while taking Atorvastatin 10mg with Ezetimibe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
490510 -            10mg. ref SDS 54 PU43                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
490512 -             ..
490513 -            [On 160715 1630 Doctor Yoo Progress Notes in Neurology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
490514 -            sets goal for LDL < 100, appears conflicting with VA
490515 -            goals for LCL < 70. ref SDS 61 O45I
490517 -             ..
490518 -            [On 170314 0817 Doctor Shunk proposed inquiry for including                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
490519 -            the patient in coronary MRI study undersay at VMCSF; Karen                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
490520 -            will follow up. ref SDS 62 A24I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
490521 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
490522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
490523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
490524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
490526 -  ..
4906 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4907 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4908 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
4909 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4910 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
491001 - Lab on 131015, showing cholesterol remained high, 131015 0724,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491002 - ref SDS 36 BE6O, conflict with increased exercise and weight loss,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
491003 - discussed in the letter to the medical team yesterday on 131016 1632.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491004 - ref SDS 37 IW57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491006 -  ..
491007 - On 131017 1000 VA medical chart Progress Notes assessment report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491008 - patient status CAD stable, asymptomatic. hyperlipidemia not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491009 - controlled. ref SDS 38 T24N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491011 -  ..
491012 - On 131017 1000 Doctor Egan proposed referring patient for clinical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491013 - trial to reduce cholesterol with new "targeted" drugs. ref SDS 38 179N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
491015 -  ..
491016 - On 131017 1000 VA medical chart Progress Notes assessment report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491017 - patient status hyperlipidemia not controlled, ref SDS 38 PSXT; Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491018 - Egan makes referral to SF VA Medical Center for consult on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
491019 - participation clinical trials, ref SDS 38 EU9F, with experimental                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
491020 - agents such as AMG 145 and REGN 727 to resolve multiple statin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491021 - intolerances. ref SDS 38 CN4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491023 -  ..
491024 - On 131103 received letter from VA SF Medical Center scheduling meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491025 - on 131121 1000, to consider clinical trial for lowering cholesteral.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491026 - ref SDS 39 YT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491027 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491028 -            Thursday November 21, 2013 1000 METAB-FELLOW-THRUSDAY Clinic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491030 -  ..
491031 - On 131112 New York Times published several articles reporting that the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491032 - day before on 131113, American Heart Association published new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491033 - guidelines for treating CAD patients that expand use of statin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491034 - medication regardless of cholesterol levels, ref SDS 40 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
491035 - further raise the LDL 70 to LDL 190, as a target for cardiovascular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491036 - risk. ref SDS 40 CW6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491038 -  ..
491039 - On 131114 New York Times published several articles reporting that the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491040 - day before on 131113, American Heart Association published new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491041 - guidelines for treating CAD patients. ref SDS 41 SH6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491042 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491043 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491045 -  ..
4911 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4912 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4913 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4914 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
491401 - Hyperlipidemia Not Controlled Cholesterol Elevated Despite Exercise                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491402 - Cholesterol Elevated Despite Exercise Discuss Clinical Trial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
491403 - Clinical Trial Considered Lower Cholesterol Without Statin Drugs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491404 - 
491405 - Follow up ref SDS 39 VY6H, ref SDS 38 VY6H.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
491406 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491407 - Meeting with Doctor Diana Alba, with UCSF Dep of Medicine, Division of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491408 - Endoncrinology and Metabolism,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491410 -  ..
491411 - We rviewed patient history showing...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491412 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491413 -    1.  Doctor Egan reported in Progress Notes patient hiked 1200 miles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491414 -        for 5 months, shown on 131017 1000, ref SDS 38 UU7J, from lab                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
491415 -        on 130529, ref SDS 32 BE6O, to lab on 131015. ref SDS 36 BE6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491417 -         ..
491418 -        Hyperlipademia evident in lab on 131015 0724, ref SDS 36 BE6O,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491419 -        appears conflicting with level of exercise.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491421 -  ..
491422 - Doctor Alba advised during the meeting today her understanding that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491423 - exercise does not stimulate production of LDL cholesterol.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
491424 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491425 -            [On 131125 0005 research found patient with high LDL 249                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
491426 -            was "healthy" with low risk for arterialsclorosis CVD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491427 -            because HDL > 50 and triglycerides < 100 so TG/HDL ratio
491428 -            below 2, indicating LDL particle size is "protective"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491429 -            because it is "large and fluffy" that cannot penetrate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491430 -            endothelial lining of artery walls. ref SDS 46 6P4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491432 -             ..
491433 -            [On 131125 0005 research indicates high LDL lipid test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491434 -            results, like LDL 249 in lab on 131015 0724, ref SDS 36                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
491435 -            BE6O, are well tolerated and even healthy, if discordant,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491436 -            ref SDS 46 OB7L, with LDL-P < 1000, ref SDS 46 K68N, if LDL
491437 -            particle size is large, and this occurs when triglycerides                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491438 -            < 100 and HDL > 50, ref SDS 46 338N; exercise increases
491439 -            HDL, ref SDS 46 W76M, and lowers triglycerides. ref SDS 46                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491440 -            QP9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491442 -  ..
491443 - Meeting agenda continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491444 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491445 -    2.  Patient diet consistes of macoroni cheese broccolli onion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491446 -        mushrooms avocado onion tomato asparagus tuna salmon, shown in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491447 -        case study on 120101 0900. ref SDS 12 7G6K  This diet nominally                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
491448 -        aids cholesterol control, shown by nutrition chart, in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491449 -        record on 070307 1322, ref SDS 1 KM7K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491451 -         ..
491452 -    3.  On 130603 0930 Medical Chart Progress Notes show Lipitor also called                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491453 -        ATORVASTATIN is listed in prescribed medications and status is "hold."                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
491454 -        ref SDS 34 YH7I  This reflects patient history suffering severe side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491455 -        effects with statin medications, reported during the meeting 5 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
491456 -        ago on 121206 0900. ref SDS 24 I05F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491458 -         ..
491459 -    4.  Research on 131112 found New York Times report AHA published                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491460 -        new guidelines that increase LDL 190 goals from LDL 70.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491461 -        ref SDS 40 P16M  Increased statin market based on unspecified                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
491462 -        studies indicating this saves lives, regardless of lowering                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491463 -        cholesterol. ref SDS 40 HK9O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
491465 -  ..
491466 - Doctor Alba advised that the VA and UCSF are still reviewing the new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491467 - AHA guidelines.  At this time the revised goal of LDL 190 has not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491468 - been accepted for VA cardiology practice.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
491470 -  ..
491471 - Meeting agenda continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491472 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491473 -    5.  Research on 131112 found that cholesterol has very high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491474 -        nutritional value, ref SDS 40 CG6I, and lists 6 health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491475 -        benefits. ref SDS 40 HC5L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491477 -         ..
491478 -        Can cholesterol be lowered without adversely affecting...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491479 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491480 -        1.  Memory and cognition............ ref SDS 40 WF4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491481 -        2.  Digestion....................... ref SDS 40 ME3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491482 -        3.  Immune system................... ref SDS 40 9K6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491483 -        4.  Sexual function................. ref SDS 40 HC5L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491484 -        5.  Vitamin D - cancer.............. ref SDS 40 6L9H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491486 -  ..
491487 - Doctor Alba commented that cholesterol has many health benefits.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491488 - cardiology practice balances benefits with avoiding death from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491489 - arterialsclorosis caused by high LDL cholestorol.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491491 -  ..
491492 - She gave an example of elevated HDL cholesterol helps resolve                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
491493 - atherosclerosis.  However, doctors have medications to prescribe for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491494 - lowering LDL, but there is no medication that will raise HDL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
491495 - Therefore cardiology practice prescirbe drugs that reach goals for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491496 - healthy LDL levels.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491497 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491499 -  ..
491500 - Meeting agenda continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491502 -    6.  Research on 131114 found New York Times criticized AHA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
491503 -        guidelines for expanding use of statins, as not based on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491504 -        science nor study evidence. 131114 0819, ref SDS 41 UJ5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491506 -         ..
491507 -        One of 2 authors who wrote this NYT Op Ed is Doctor Rita F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491508 -        Redberg, a cardiologist at the University of California, San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491509 -        Francisco Medical Center and the editor of JAMA Internal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491510 -        Medicine. ref SDS 41 7J31                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491512 -  ..
491513 - Doctoe Alba could not find contact information for Doctor Redbert in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491514 - Cardiology at UCSF.  She will make further inquiies after the meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491515 - about engaging Doctor Redberg to support the Welch case,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
491517 -  ..
491518 - Meeting agenda continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491520 -    7.  Patient history taking statins caused severe side effects of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491521 -        myopathy, dizziness, parathesia, and dehydration from increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491522 -        urination, reported in Doctor Egan's Progress notes for meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491523 -        on 131017 1000, ref SDS 38 PR5G and ref SDS 38 TX50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491525 -            [On 140213 0830 patient initially suffered minimal side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491526 -            effects taking minimal dose Atorvastatin 10 mg and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
491527 -            Ezetimibe 10 mg for only 2 months. ref SDS 53 JT3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491529 -         ..
491530 -    8.  Objectives                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491532 -        1.  Might a study be fashioned to evaluate maintaining good health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
491533 -            through diet and exercise compared with using statins?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491535 -            The goal to lower cholesterol is to maintain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
491536 -            cardiovascular health, including regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
491537 -            atherosclerosis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491538 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491539 -               [On 131125 0005 research finds ezetimibe (zetia) for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491540 -               secondary drug recommended by "expert" to treat high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491541 -               risk CAD patient, ref SDS 46 XG4N, where LDL-P is high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
491542 -               and discordant with low LDL-C, approximated by TG/HDL-C                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491543 -               ratio < 2, ref SDS 44 QS9F, which is shown by evidence
491544 -               in this case from lab on 131015 0724. ref SDS 36 BE6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
491546 -                ..
491547 -               [On 131216 0028 letter to Doctor Alba and medical team                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
491548 -               submits pending issues to discuss during meeting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491549 -               131219. ref SDS 50 8N50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491551 -             ..
491552 -        2.  Targeted drug treatment to lower cholesterol without side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491553 -            effects.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491555 -             ..
491556 -            PCSK9 drugs being developed and tested in clinical trials                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491557 -            by Amgen and Regeneron, reported last year on 120325 1312,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491558 -            ref SDS 15 QG8R, was discussed with Doctor Egan during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491559 -            meeting at the VA on 131017. ref SDS 38 PS4M  At that time,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
491560 -            Doctor Egan reported in Progress Notes of patient medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491561 -            chart that assessment of patient status indicates                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
491562 -            hyperlipidemia not controlled, ref SDS 38 PSXT; Doctor Egan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
491563 -            made referral to SF VA Medical Center for consult on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491564 -            participation clinical trials, ref SDS 38 EU9F, with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491565 -            experimental agents such as AMG 145 and REGN 727 to resolve                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491566 -            multiple statin intolerances. ref SDS 38 CN4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491568 -               [...below on 131121 0930 at 1125 suggestion to ask                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491569 -               Doctor Kane at UCSF about clinical trials for non-statin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491570 -               drugs. ref SDS 0 MZ4K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491572 -                ..
491573 -               [...below on 131121 0930 VA Progress Notes in medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
491574 -               chart report consideration for patient to participate in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491575 -               clinical trial testing PCSK9 drugs to manage cholesterol                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491576 -               for lowering CVD risk through regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
491577 -               atherosclerosis. ref SDS 0 Q17I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
491578 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491580 -  ..
491581 - Atorvastatin 4-week Trial Predicate Clinical Trial Add Zetia 10 MG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491582 - 
491583 - Doctor Alba prescribed trying Atorvastatin (Lipitor) 10 mg for 4 weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491584 - to assess lowering cholesterol LDL 249.  Will then evaluate adding a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491585 - 2nd drug, Zetia 10 mg, which together are intended to lower                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491586 - cholesterol and to reduce side effects from taking statin drugs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491587 - alone.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491589 -             ..
491590 -            [...below on 131121 0930, VA Progress Notes reflect                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491591 -            understadings to take Atorvastatin 10 mg low dose for a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491592 -            period of 4 weeks to test tolerance, then assess adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491593 -            Ezetimibe 10 mg. ref SDS 0 S26O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
491595 -             ..
491596 -            [On 131121 1604 in another record later today, VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491597 -            prescription RX # 5674471 for Atorvastatin 20 mg has been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491598 -            ordered. ref SDS 43 GH5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
491600 -             ..
491601 -            [On 131125 0005 letter from Karen reports VA work plan to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
491602 -            take statin drug low dose Atvorstatin 10 mg for 4 weeks,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491603 -            then add Zetia 10 mg in clinical trial for lowering                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
491604 -            cholesterol. ref SDS 45 V154                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
491606 -             ..
491607 -            [On 131125 0005 research seems to indicate this clincial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
491608 -            trial of low dose Atorvasatatin 10 mg with Zeitia 10 mg has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491609 -            lowered cholesterol to LDL < 70. ref SDS 44 WL7I
491611 -             ..
491612 -            [On 131125 0005 research found ezetimibe (Zetia) mg added                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
491613 -            to Atorvastatin 20 mg yielded significantly greater changes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491614 -            to HDL and Triglycerides (TG), than taking Atorvastatin in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491615 -            higher doses, e.g., 20 or 40 mg. ref SDS 46 CO56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491617 -             ..
491618 -            [On 131125 0005 research finds ezetimibe (Zetia) for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491619 -            secondary drug recommended by "expert" to treat high risk                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491620 -            CVD patient, ref SDS 46 XG4N, where LDL-P is high and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491621 -            discordant with low LDL-C, approximated by TG/HDL-C ratio <
491622 -            2, ref SDS 44 QS9F, which is shown by evidence in this case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
491623 -            from lab on 131015 0724. ref SDS 36 BE6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
491625 -             ..
491626 -            [On 131125 0005 research study finds Atorvastatin 10 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491627 -            combined with ezetimibe 10 mg yielded 0.4% regression                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491628 -            atherosclerosis plaques over 1 year. ref SDS 47 Z56P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491630 -             ..
491631 -            [On 131205 1448 received new prescription for Atvorstatin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
491632 -            20 mg, ordered by Doctor Alba today for 4-week trial to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491633 -            assess side effects for adding 2nd drug, Zetia 10 mg to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491634 -            lower LDL 249. ref SDS 48 GH5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491636 -             ..
491637 -            [On 131216 0028 letter to Doctor Alba and medical team                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491638 -            submits pending issues to discuss during meeting on 131219.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491639 -            ref SDS 50 8N50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491641 -             ..
491642 -            [On 131230 1450 received prescription for Ezetimibe,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
491643 -            ref SDS 52 5N3O, so begin trial Atorvastatin 10 mg and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
491644 -            Ezetimite 10 mg to manage cholesterol, shown in case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491645 -            on 120101 0900. ref SDS 13 6A6H
491647 - -
491648 - Side effects of Atorvastatin (Lipitor) were reviewed with Doctor Egan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491649 - during meeting at VA on 130603 0930. ref SDS 33 PC6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
491651 -  ..
491652 - Will meet again in 4 weeks to review results of Doctor Alba's research                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491653 - for a clinical trial that does not involve statin drugs; and decide on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491654 - best course of care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
491656 -  ..
491657 - This evening started taking Atorvastatin 40 mg, reported in case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491658 - on 120101 0900, ref SDS 12 RN3F, and on hand from prior prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
491659 - ordered by Doctor Egan, shown in Progress Notes for meeting on 130603                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491660 - 0930. ref SDS 33 1X3L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
491662 -             ..
491663 -            [On 131125 0005 research found ezetimibe (zetia) mg added                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
491664 -            to Atorvastatin 20 mg yielded significantly greater changes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491665 -            to HDL and Triglycerides (TG), than taking Atorvastatin in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491666 -            higher doses, e.g., 20 or 40 mg. ref SDS 46 CO56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491668 -             ..
491669 -            [On 131125 0005 research found dizziness less common side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
491670 -            effect taking ezetimibe (zetia). ref SDS 44 JO6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
491672 -             ..
491673 -            [On 131205 1448 received new prescription for Atvorstatin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
491674 -            20 mg, ordered by Doctor Alba today for 4-week trial to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491675 -            assess side effects for adding 2nd drug, Zetia 10 mg to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491676 -            lower LDL 249. ref SDS 48 GH5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491678 -             ..
491679 -            [On 131216 0028 letter to Doctor Alba and medical team                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
491680 -            submits pending issues to discuss during meeting on 131219.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491681 -            ref SDS 50 8N50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
491683 -             ..
491684 -            [On 140430 0900 letter to VA notifies some minor dizziness                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
491685 -            has begun while taking Atorvastatin 10mg with Ezetimibe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
491686 -            10mg. ref SDS 54 PU43                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
491687 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491688 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491689 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491690 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491691 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
491693 -  ..
4917 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4918 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4919 - 1125                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
4920 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
492001 - Met with Karen and Doctor Shrunk in Cardiology located in Building 203                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492002 - across the street from the clinics.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492004 -  ..
492005 - Karen was pleased to hear former cabg x4 patient in 2009, climbed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492006 - Half Dome in Yosemite this past September 18, 2013.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492007 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492008 -            [On 131125 0005 letter to Karen confirms understandings                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492009 -            from meeting at VA SF Medical Center today, ref SDS 44                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
492010 -            HY6O, and commend VA for excellent care. ref SDS 44 UK3R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492012 -  ..
492013 - We discussed testing for regression of atherosclerosis based on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492014 - increased endurance exercise this year to prepare for Half Dome, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492015 - continuing into Ocotober, November, listed in case study on 120101,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492016 - showing...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
492017 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492018 -                2013                 Miles        Source                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
492019 -                April................ 140........ ref SDS 12 Q48M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492020 -                May.................. 302........ ref SDS 12 QG3F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492021 -                June ................  89........ ref SDS 12 765L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492022 -                July................. 172........ ref SDS 12 T78G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492023 -                August............... 297........ ref SDS 12 554N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492024 -                September............ 225........ ref SDS 12 419J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492025 -                October.............. 373........ ref SDS 12 6F9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492027 -  ..
492028 - Doctor Shunk cautioned against doing an invasive surgical procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492029 - solely to assess regression of atherosclerotic plaques, like the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492030 - angiogram study he did on 091021, ref SDS 3 7L43, which led to CABG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492031 - +4 heart surgery the next day, brilliantly performed by Doctor Tseng,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492032 - and her team on 091022. ref SDS 4 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492033 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492034 -            [On 170314 0817 Doctor Shunk proposed inquiry for including                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
492035 -            the patient in coronary MRI study undersay at VMCSF; Karen                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492036 -            will follow up. ref SDS 62 A24I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492038 -  ..
492039 - We considered non-invasive methods, for example after Doctor Shunk did                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492040 - invasive angiography in the early morning of 091021 0716, Irene later                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492041 - performed ultrasound procedure that tested blood flow to the brain on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492042 - 091021 0716 at 1207. ref SDS 3 04CH  This non-invasive test verfied                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492043 - patient was a viable candidate for CABG performed the next day on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492044 - 091022.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
492046 -  ..
492047 - Today, there was not enough time for further discussion.  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492048 - Shunk and Karen urged further research for effective non-invasive                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492049 - modalities to test for response to treatment that regresses                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
492050 - atherosclerosis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492052 -             ..
492053 -            [On 131125 0005 research found regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
492054 -            atherosclerosis occurs rapidly with endurance exercise that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492055 -            increases endothelial progenitor cells (EPC) produced by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492056 -            bone marrow, similar to WBC, ref SDS 44 1855, and increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492057 -            production of HDL cholesterol mainly in the liver and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492058 -            intestine, ref SDS 44 RA7K; non-invasive coronary CTA with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
492059 -            calcium score can test for response to treatment with high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492060 -            levels of endurance exercise for regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492061 -            atherosclerosis. ref SDS 44 278M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492063 -             ..
492064 -            [On 140515 letter to medical team reports visiting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492065 -            San Francisco Medical Center Radiology Department on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492066 -            doing coronary CTA assess regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492067 -            atherosclerotic plaques resulting from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492068 -            interventions, including CABG +4 on 091022, with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
492069 -            subsequent high levels of hyperlipedimeia (LDL 249),                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492070 -            followed by dramatic decline in LDL-P and rise of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492071 -            HDL. ref SDS 55 YM41                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492073 -             ..
492074 -            [On 140805 1030 meeting Karen in Cardiology Administration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492075 -            discussed testing with coronary CTA and calcium score                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492076 -            standard of care to evaluate response to treatment for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492077 -            regression of atherosclerosis based on hiking 300 miles per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492078 -            month that lowered LDL-P 851, HDL 67 TG 58. ref SDS 56 IW6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492080 -             ..
492081 -            [On 150526 1148 Karen recommended consulting Doctor Simpson                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
492082 -            on ordering CCTA for testing response to treatment for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492083 -            regressing atherosclerosis, toward lowering line of care in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492084 -            order reduce debilitating side effects. ref SDS 57 3G4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
492086 -             ..
492087 -            [On 150925 0336 Karen in Cardiology asked schedule Clerk,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
492088 -            Joe, to schedule meeting with Doctor Simpson for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
492089 -            consultation on ordering CCTA. ref SDS 58 GK9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492091 -             ..
492092 -            [On 151014 0900 meeting with Doctor Simpson scheduled CCTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492093 -            with calcium score on 151019 0930. ref SDS 59 OG3N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492095 -             ..
492096 -            [On 151019 0930 CCTA with calcium score performed; meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492097 -            with doctor in Radiology Department reviewed requirements                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492098 -            for calcium score to evaluate response to treatment                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
492099 -            recovering from atherosclorosis. ref SDS 60 GR4K  At the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492100 -            end of the meeting, the doctor agreed to perform calcium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492101 -            score for comprehensive CCTA test. ref SDS 60 LQ5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492103 -             ..
492104 -            [On 170314 0817 Doctor Shunk proposed inquiry for including                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
492105 -            the patient in coronary MRI study undersay at VMCSF; Karen                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492106 -            will follow up. ref SDS 62 A24I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492107 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492109 -  ..
492110 - Karen advised that Doctor Tseng has been promoted to Chief of Surgery,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492111 - taking over for retiring Doctor Ratcliffe.  Elaine was attending for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492112 - cabg x4 surgery on 091022 0700. ref SDS 4 PQWU  Doctor Ratcliffe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492113 - supervised recovery after Doctor Tseng was on vacation for a week,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492114 - e.g., reviewing feeding tube issue on 091030 0810. ref SDS 5 03GF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
492115 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492116 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492118 -  ..
492119 - Chia Seeds Lower Cholesterol Control Weight Increase Energy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492120 - 
492121 - Karen suggested trying Chia seeds to lower cholesterol without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
492122 - medications.  She indicated Chia seeds boost energy as well.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492123 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492124 -            [On 120101 0900 case study reports on 131125, began adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492125 -            Chia seeds to daily diet. ref SDS 13 746M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
492127 -             ..
492128 -            [On 131125 0005 letter notifies Karen implemented                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492129 -            suggestion adding Chia seeds to daily diet. ref SDS 46 YU66                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492130 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492132 -  ..
492133 - Later, research on the Internet found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
492134 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492135 -            CHIPRX.COM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492136 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492137 -            Fitness                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492138 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492139 -            How Chia Seeds Can Benefit Your Health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492140 -            6 Great Reasons to Start Eating Chia Seed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492141 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492142 -              http://www.chiprx.com/chia-seeds-benefit-health-6-great-reasons-start-eating-chia-seed/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
492144 -             ..
492145 -            Chia seeds are becoming a popular nutritional item thanks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492146 -            to all the attention it has been getting on TV shows like                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492147 -            Dr OZ.  However, they have been around for years as people                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492148 -            from various cultures from as far back as the BC era have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492149 -            used it to help treat medical problems like joint pain.  A                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492150 -            member of the mint family, Chia is mainly produced in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492151 -            Mexico and provides a bunch of health benefits that people                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492152 -            are beginning to use as an important part of a healthy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492153 -            diet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492155 -             ..
492156 -            Health Benefits of Chia Seeds                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
492157 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492158 -            1.  Omega 3 Fatty Acids                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492159 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492160 -                Omega 3 fatty acids have some of best anti-inflammatory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492161 -                properties available in nature. Chia seeds have the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492162 -                most omega 3 fatty acids than any other plant out                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492163 -                there.  These essential fats can help decrease                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
492164 -                inflammation and pain your body may be experiencing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492165 -                Along with reducing inflammation the omega 3 fatty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492166 -                acids naturally found in chia seeds can improve your                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492167 -                cognitive function, decrease high cholesterol, and keep                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492168 -                your joints lubricated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492170 -                 ..
492171 -            2.  Protein                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492172 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492173 -                Everybody needs protein, as it is an essential part of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492174 -                every cell inside our body.  Everything from our hair                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492175 -                to nails is made up of protein. Protein helps to build                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492176 -                your bones, muscles, skin, and helps repair damaged                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492177 -                tissues.  Chia seeds are packed with this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
492178 -                macronutrient.  In fact, just 1 ounce of chia seeds has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492179 -                4.4 grams of protein.  If you are a vegan then chia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492180 -                seeds should be included in your daily diet to make                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492181 -                sure your body gets all the complete protein it needs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492183 -                 ..
492184 -            3.  Fiber                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492185 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492186 -                Chia seeds is a rich source of fiber which can help                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492187 -                decrease inflammation, keep your bowel functioning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492188 -                properly, increase weight loss, and decrease your                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492189 -                cholesterol. Just two tablespoons of chia contains at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492190 -                least 10 grams of fiber, which will give you most of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492191 -                your daily recommended fiber intake.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492193 -                 ..
492194 -            4.  Antioxidants                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
492195 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492196 -                Antioxidants are the compounds your body needs to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492197 -                fight off certain diseases, infections, and cancers.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492198 -                Chia is a great source of various antioxidants like                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492199 -                quercetin, myricetin, and cholorgenic acid. These                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492200 -                antioxidants that chia packs can benefit you in more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492201 -                ways than one when it comes to your health. For                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
492202 -                example, chlorogenic acid has great anti-cancer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
492203 -                properties that can kill free radicals that cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492204 -                certain cancers.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492206 -                 ..
492207 -                This antioxidant can also help you slow down the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492208 -                release of glucose in your bloodstream after you eat,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492209 -                and help you decrease your chances of experiencing Type                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492210 -                2 Diabetes.  These antioxidants naturally found in chia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492211 -                seeds can also help improve your heart health and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492212 -                improve the health of your liver and gallbladder.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492214 -                 ..
492215 -            5.  Minerals                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
492216 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492217 -                Chia is a fantastic source of minerals like potassium,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492218 -                magnesium, calcium, and manganese that can help you                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492219 -                lower your high blood pressure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
492221 -                 ..
492222 -            6.  Using Chia Seeds For Health Problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492224 -                 ..
492225 -                With all these different essential nutrients that chia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492226 -                seeds contain you can see why it is important to start                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492227 -                eating them.  Check out some of the health problems you                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492228 -                can use chia seeds to remedy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492230 -                 ..
492231 -            7.  Weight Loss                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
492232 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492233 -                Eating chia seeds can help you reduce your appetite                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492234 -                because of the rich amount of fiber it contains.  Chia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492235 -                will help block the absorption of calories, which will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492236 -                help your diet be successful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492238 -                 ..
492239 -            8.  Arthritis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
492240 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492241 -                Arthritis can cause a lot of pain in your joints.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492242 -                more chia seeds you eat the more lubricated your joints                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492243 -                will be, which will reduce the pain associated with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492244 -                this condition.  The omega 3 fatty acids in chia will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492245 -                give you the anti-inflammatory properties you need to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492246 -                decrease the swelling.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492248 -                 ..
492249 -            9.  Diabetes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
492250 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492251 -                Since chia seeds are effective at regulating carbs and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492252 -                the sugars they are converted into.  Chia will create a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492253 -                barrier inside your stomach to assist with slowing down                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492254 -                the digestion of sugar in your blood, which will help                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492255 -                keep a diabetics glucose level down.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492257 -                 ..
492258 -           10.  Skin, Hair, & Nail Health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492259 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492260 -                Thanks to the essential fatty acids found in chia this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492261 -                food item can keep your nails, hair, and skin looking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492262 -                youthful.  These seeds will keep your body hydrated and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492263 -                moisturized to fight of dry and irritated skin.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
492265 -                 ..
492266 -           11.  Heart Health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
492267 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492268 -                If you want to avoid heart problems like cardiovascular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492269 -                disease it is a good idea to add chia to your diet.  It                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492270 -                is the essential fatty acids in chia that can add more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492271 -                good cholesterol to your system and reduce the amount                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492272 -                of bad cholesterol.  Bad cholesterol, also known as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492273 -                LDL, is a huge cause of heart disease so anything you                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492274 -                can do to reduce this cholesterol will improve your                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492275 -                heart health.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492277 -                 ..
492278 -           12.  Increase Your Energy Level                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492279 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492280 -                The hydrophilic properties in chia seeds can assist you                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492281 -                with regulating your electrolytes which will have a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492282 -                positive effect on your energy levels.  Chia contains                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492283 -                complex carbs that will gradually break down over time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492284 -                in your system so your energy levels stay up for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492285 -                enhanced stamina.  The essential fatty acids in chia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492286 -                like omega 3 will improve your mood and mental energy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492288 -                 ..
492289 -           13.  How to Add Chia To Your Diet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
492290 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492291 -                You can add chia seeds to just about anything you eat.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492292 -                Add it to your cereal, salads, or add them to your                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492293 -                favorite baked item before you put it in the oven to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492294 -                bake.  You can also eat the seeds just as they are or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492295 -                use them to make a smoothie.  Finally, you can try                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492296 -                making a chia paste by soaking the seeds for around                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492297 -                thirty minutes until a clear paste forms.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
492299 -                 ..
492300 -           14.  John is a health enthusiast that writes on various                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
492301 -                health topics.  He is currently doing some online                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492302 -                research at Wart Removal Experts on natural ways to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
492303 -                remove warts.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492304 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492305 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492306 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492308 -  ..
492309 - Karen indicated Doctor John Kane at UCSF is a good contact for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
492310 - participating in a clinical trial of new targeted and non-static drugs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492311 - - PCSK9, discussed with Doctor Alba earlier this morning, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492312 - ref SDS 0 545O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
492314 -  ..
492315 - Doctor Shunk provided helpful guidance to focus on lowering LDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492316 - cholesterol along with lifestyle of healthy diet and exercise.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
492318 -  ..
492319 - Karen indicated that Doctor Kane is a good contact for lipid trials.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492320 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492321 -            [On 131125 0005 letter from Karen reports VA work plan to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
492322 -            take statin drug low dose Atvorstatin 10 mg for 4 weeks,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492323 -            then add Zetia 10 mg in clinical trial for lowering                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
492324 -            cholesterol. ref SDS 45 V154                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
492326 -             ..
492327 -            [On 131125 0005 research finds ezetimibe (zetia) for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
492328 -            secondary drug recommended by "expert" to treat high risk                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
492329 -            CVD patient, ref SDS 46 XG4N, where LDL-P is high and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492330 -            discordant with low LDL-C, approximated by TG/HDL-C ratio <
492331 -            2, ref SDS 44 QS9F, which is shown by evidence in this case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
492332 -            from lab on 131015 0724. ref SDS 36 BE6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
492334 -             ..
492335 -            [On 131216 0028 letter to Doctor Alba and medical team                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
492336 -            submits pending issues to discuss during meeting on 131219.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
492337 -            ref SDS 50 8N50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
492338 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492339 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492340 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492341 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
492342 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
4924 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Examination Progress Notes Endocrinology Medical Chart Meeting 13112                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
5903 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590401 -  ..
590402 - Medical Chart Progress Notes Meeting 131121 VA SF Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590403 - 
590404 - Follow up ref SDS 38 TF5O. ref SDS 34 TF5O.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590406 -    1.  LOCAL TITLE:  ENDOCRINE-METABOLISM CLINIC (MED)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590407 -        STANDARD TITLE:  ENDOCRINOLOGY OUTPATITNE NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590408 -        DATE OF NOTE:  NOV 21, 2013 @ 0956                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
590409 -        ENTRY DATE:  NOV 21, 2013 @095641                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590419 -         ..
590420 -        CC:  high cholesterol                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590422 -         ..
590423 -    2.  HPI:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590424 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590425 -        1.  68 year old male with history of CAD, s/p CABG in 2009,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590426 -            Hyperlipidemia, achalasia, s/p lap heller myotomy and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590427 -            fundoplication in 2009, who was referred by his Cardiologist,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590428 -            Doctor Egan for management of hyperlipidemia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590430 -             ..
590431 -        2.  Patient was started on Simvastatin approximately 2-3 years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590432 -            ago, LDL at that time was around 180's - reports this his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590433 -            LDL dropped to 96 while on simvastatin, however he reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590434 -            he develop "left shoulder myopathy"- he described pain on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590435 -            his left shoulder and inability to raise it above 90                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590436 -            degrees- No CPK on records.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590438 -             ..
590439 -        3.  He was then started on Rosuvastatin 10 mg po daily and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590440 -            report that his LDL improved.  Rosuvastatin was then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590441 -            increased to 20 mg and he developed sexual dysfunctio,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590442 -            dizziness, dry mouth and right foot numbness.  As per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590443 -            cardiology notes in September 2012- rosuvastatin was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590444 -            decreased to 10 mg po daily and dizziness improved, but he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590445 -            continued to complain of right foot numbness.  He now has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590446 -            he has been off the rosuvastatin since 12/2012, and he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590447 -            continues to complain of right foot nmbness, but he reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590448 -            less episodes of right sole numbness with decreased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590449 -            intensity.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590451 -  ..
590452 - Comment...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
590454 -  ..
590455 - Over the past year there have been 7 episodes while hiking of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590456 - peripheral neuropathy (parethesia, numbness, tingling) documented in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590457 - the record after ending Rosuvastatin on 121206.  These events subsided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590458 - within .5 to 1 mile, as follows...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590459 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590460 -        1.  Left foot after 1.5 miles.......... 121212, ref SDS 12 VH5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590462 -             ..
590463 -        2.  Right foot after 1 mile............ 130107, ref SDS 12 8H5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590464 -            Left foot after 1.5 miles.......... 130107, ref SDS 12 8H5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590466 -             ..
590467 -        3.  Right foot after .25 miles......... 130210, ref SDS 12 PV8I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590468 -            Left foot after 2 miles............ 130210, ref SDS 12 PV8I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590470 -             ..
590471 -        4.  Right foot after .5 miles.......... 130604, ref SDS 12 X14N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590473 -             ..
590474 -        5.  Right foot after .5 miles.......... 130609, ref SDS 12 8G5L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590476 -             ..
590477 -        6.  Right foot after .5 miles.......... 130610, ref SDS 12 TH3K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590479 -             ..
590480 -        7.  Right foot after .5 miles.......... 130614, ref SDS 12 TSUY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590482 -  ..
590483 - VA Progress Notes HPI continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590484 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590485 -            Of note, he was seen by neurology February 2013 for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590486 -            foot numbness, Vit B12 level was within normal range,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590487 -            fasting glucose level ranges from 108 to 115 mg/dl, Hgalc                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590488 -            5.5 October 2013, as per neurology notes no evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590489 -            radiculopathy or neuropathy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590491 -  ..
590492 - Patient history shows meeting with Doctor Abrams on 130227 0930.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590493 - ref SDS 28 PPWW  At that time, the doctor indicated no evidence for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
590494 - spinal stenosis causing peripheral neuropathy. ref SDS 28 UT6T  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
590495 - doctor ordered HGA1c lab. 130227 0930, ref SDS 28 P44K  However, it is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590496 - not reported for the lab performed the next day on 130228 1140,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590497 - ref SDS 29 RP4N, nor in the follow up lab 3 months later on 130529                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590498 - 0818. ref SDS 32 RP4N  HGA1c 5.5 range 4.1 - 6, was reported for lab                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
590499 - on 131015 0724. ref SDS 36 9F4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590501 -  ..
590502 - VA Progress Notes HPI continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590504 -        8.  Mr Welch would like to be part of a clinical trial for a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590505 -            new lipid lowering medication; in particular he is asking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590506 -            about AMG 145- PCSK9 inhibitors.  Regarding other lipid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590507 -            lowering agents, he has never Zetia, has been offered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590508 -            colestipol as per records, but concerned for midly elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590509 -            total bilirubin [1.7].                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590511 -  ..
590512 - This aligns with discussion on participating clinical trial, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590513 - above, ref SDS 0 545O, based on Doctor Egan's Progress Notes with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590514 - assessment that patient hyperlipidemia not controlled, ref SDS 38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590515 - PSXT; Doctor Egan made referral to SF VA Medical Center for consult on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590516 - participation clinical trials, ref SDS 38 EU9F, with experimental                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590517 - agents such as AMG 145 and REGN 727 to resolve multiple statin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590518 - intolerances. ref SDS 38 CN4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590520 -  ..
590521 - PCSK9 drugs being developed independently by Amgen and Regeneron                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590522 - presents an alternative to statin drugs for treating atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590523 - was reported in an article reviewed on 120325 1312. ref SDS 15 QG8R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
590524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590525 -               [...below on 131121 0930 VA Progress Notes in medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590526 -               chart report plan to investigate clincial trials to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590527 -               treat atherosclerosis with PCSK9 drugs, rather than                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590528 -               statins. ref SDS 0 X53M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590530 -  ..
590531 - VA Progress Notes Meeting 131121 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590533 -        9.  He denies CP, SOB, Denies abdominal pain, muscle pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590534 -            Reports occassional right foot numbness.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590536 -             ..
590537 -       10.  He is very active- hikes 2-4 times per week- about 14                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590538 -            miles.  Reports low fat/low cholesterol diet, avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590539 -            processed and fried foot                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590541 -  ..
590542 - Patient history shows for past 2 years patient hikes 11 miles per day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590543 - 4 - 5 times per week, shown in case study on 120101 0900. ref SDS 12                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
590544 - QJ5I  Past 6 months patient hikes 5 - 7 times per week, 11 miles per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590545 - day. ref SDS 12 YI5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
590547 -  ..
590548 - VA Progress Notes Meeting 131121 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590549 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590550 -    3.  PMH:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590551 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590552 -        1.  Esophageal Achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590553 -        2.  CAD s/p CABG x4 in 2009                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590554 -        3.  GERD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590555 -        4.  Hyperlipidemia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
590557 -         ..
590558 -    4.  PSH:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590559 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590560 -        1.  CABG (10/22/2009)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590561 -        2.  Left knee repair                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590562 -        3.  Lap heller myotomy, fundoplication December 2009                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590563 -        4.  EGD dilations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590565 -         ..
590566 -    5.  MEDICATIONS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590568 -        1.  Omeprazole 20 mg BID                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590570 -         ..
590571 -    6.  Social History:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590572 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590573 -        1.  Tobacco:  Denies smoking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590574 -        2.  Alcohol:  social                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590575 -        3.  Ilicit drugs:  denies                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590577 -         ..
590578 -    7.  Family History:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590579 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590580 -        1.  Father:  stroke age 65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590581 -        2.  Mother:  deceased " old age"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590582 -        3.  7 brothers/sisters:  healthy-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590583 -        4.  Denies family hx of high cholesterol, heart disease                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590585 -  ..
590586 - Comment...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
590588 -  ..
590589 - Older sister, died from lung cancer at age 58.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590591 -  ..
590592 - Younger sister died at about age 55 from unknow causes, was way                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590593 - overweight, drank and smoked.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590595 -  ..
590596 - There is no record of high cholesterol nor heart disease, so patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590597 - can neither deny nor affirm family history on these issues.  Seems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590598 - likely father suffered high cholesterol, and seems likely younger                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590599 - sister did as well.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590600 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590601 -            [On 131216 0028 corrections to family history were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590602 -            submitted to the VA. ref SDS 50 8N61                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590604 -  ..
590605 - VA Progress Notes HPI continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590606 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590607 -    8.  PHYSICAL EXAM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590609 -        1.  Vital Signs:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590610 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590611 -            1.  HT:  66 in [167.6 cm] (12/16/2009 1800)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590612 -            2.  WT:  178.8 lb [81.3 kg] (11/21/2013 0947)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590613 -            3.  HR:  60 (11/21/2013 0947)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590614 -            4.  BP:  129/75 (11/21/2013 0947)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590615 -            5.  Temp:  97.1 F [36.2 C] (12/20/2009 0846)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590616 -            6.  O2 Sat:  11/21/13 094703  091                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590617 -            7.  BMI:  28.9 (Overweight)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590619 -             ..
590620 -        2.  Gen    :  NAD, AAO x3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590622 -             ..
590623 -        3.  HEENT  :  NC/AT, MMM, PERRL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590625 -             ..
590626 -        4.  Neck   :  supple, no thyromegaly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590628 -             ..
590629 -        5.  CARDIO :  BRR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590631 -             ..
590632 -        6.  LUNGS  :  CTA Bl, no wheeze                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590634 -             ..
590635 -        7.  ABD    :  soft, NT/ND.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590637 -             ..
590638 -        8.  EXT    :  no edema, no cyanosis, no xanthemas, no achiles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590639 -                      tendon thickening                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590641 -         ..
590642 -    9.  LABS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590643 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590644 -        1.  October 2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590645 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590646 -            TC............. 321                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590647 -            LDL............ 249                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590648 -            HLD............ 50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590649 -            TG............. 85                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590650 -            TBil........... 1.7                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590652 -  ..
590653 - HLD 50 should be HDL 50 - minor correction.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590655 -  ..
590656 - Triglycerides (TG) reported 109 not 85, for lab on 131015 0724.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590657 - ref SDS 36 BE6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590658 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590659 -            [On 131219 0930 Progress Notes for next meeting repeats                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590660 -            error reporting TG 85, should be 109. ref SDS 51 FJ6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590662 -  ..
590663 - VA Progress Notes LABS continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590664 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590665 -        2.  May 2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590666 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590667 -            TC............. 307                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590668 -            LDL............ 240                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590669 -            HLD............ 54                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590670 -            TG............. 85                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590671 -            TBil........... 1.3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590673 -             ..
590674 -        3.  November 2012                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590675 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590676 -            TC............. 173                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590677 -            LDL............ 105                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590678 -            HLD............ 57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590679 -            TG............. 53                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590680 -            TBil........... 1.6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590681 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590682 -        4.  14 December 2009                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590683 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590684 -            TC............. 241 H    100 - 240   PLASMA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590685 -            LDL (Calcultd). 170 H        - 131   PLASMA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590686 -            HLD............ 44        35 -       PLASMA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590687 -            TG............. 136       10 - 190   PLASMA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590689 -         ..
590690 -   10.  Assessment and Plan:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590691 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590692 -        1.  68 year old male with history of CAD, s/p CABG in 2009,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590693 -            Hyperlipidemia, referred by cardiology for management of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590694 -            hyperlipidemia.  Most recent LDL 249 in a patient with known                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590695 -            CAD- unclear history of myopathy secondary to simvastatin,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590696 -            and neuropathy and sexual dysfunction secondary to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590697 -            Rosuvastatin.  Regarding history to right foot numbness, he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590698 -            continues to have symptoms despite been off Rosuvastatin for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590699 -            10 months now, so unclear casual effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590701 -  ..
590702 - Comment...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
590704 -  ..
590705 - Patient history shows peripheral neuropathy (parathesia - numbness,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590706 - tingling) first reported on 120422 - see case study on 120101 0900.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590707 - ref SDS 12 RQQT  Rosuvastatin 10 mg started on 110823, see case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590708 - on 101010 0744. ref SDS 7 KF8O  Rosuvastatin 20 mg began daily use on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590709 - 120208. ref SDS 12 RR4F  Severely debilitating peripheral neuropathy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
590710 - occurred on 120513, see case study on 120101. ref SDS 12 F97O  Similar                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590711 - episode on 120625. ref SDS 12 7G5M  Patient history continues showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
590712 - daily episodes until Rosuvastatin ended on 121206, ref SDS 12 GC6N,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
590713 - e.g., standing in waiting room at VA to get lab, right foot went numb                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590714 - - had to walk through halls to relieve condition. ref SDS 12 X75H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590715 - Over the past year, peripheral neuropathy right foot has gradually                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590716 - subsided in frequency and intensity.  No reports of episodes for past                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590717 - 2 months; however, very occasionally, while standing in line, e.g.,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590718 - Costco, may feel slight thickness in right foot - could be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
590719 - imagination.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590721 -  ..
590722 - VA Progress Notes Assessment and Plan continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590723 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590724 -        2.  Prolonged discussion of best approach to treat hyperlipdemia,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590725 -            patient understands that LDL goal < 70.  He also understands
590726 -            that despite appropriate diet and exercise, his LDL is still                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590727 -            not at goal, and increasing exercise activity is of little                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590728 -            benefit at this point, since elevated cholesterol in his case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590729 -            has a genetic component, that needs to be treated with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590730 -            medication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590732 -               ..
590733 -              [On 160715 1630 Doctor Yoo Progress Notes in Neurology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590734 -              sets goal for LDL < 100, appears conflicting with VA
590735 -              goals for LCL < 70. ref SDS 61 O45I
590737 -             ..
590738 -        3.  He agrees to try Atorvastatin lwo dose, it seems it was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590739 -            prescribed in the past, but patient reports not taking it.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590741 -             ..
590742 -        4.  We need to do combination therapy, so we can add Zetia 10 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590743 -            daily.  Patient is hesitant to start both medications at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590744 -            same time for fear of possible side effects, so agrees to try                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590745 -            Atorvastatin for 4 weeks, and monitor any side effects, then we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
590746 -            can add Zetia and recheck lipids.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590748 -             ..
590749 -        5.  Plan:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590750 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590751 -            1.  Trial of Atorvastatin 10 mg po daily, if tolerated we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590752 -                can increase to maximum dose to reach LDL goal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590753 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590754 -            2.  Start Zetia 10 mg po daily in 4 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590756 -  ..
590757 - This plan aligns with understandings from meeting today, as shown in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590758 - the record above. ref SDS 0 6H6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590760 -                   ..
590761 -                  [On 131125 0005 research finds ezetimibe (zetia) for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
590762 -                  secondary drug recommended by "expert" to treat high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590763 -                  risk CAD patient, ref SDS 46 XG4N, where LDL-P is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590764 -                  high and discordant with low LDL-C, approximated by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590765 -                  TG/HDL-C ratio < 2, ref SDS 44 QS9F, which is shown
590766 -                  by evidence in this case from lab on 131015 0724.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590767 -                  ref SDS 36 BE6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590769 -                   ..
590770 -                  [On 131125 0005 research found ezetimibe (zetia) mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590771 -                  added to Atorvastatin 20 mg yielded significantly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590772 -                  greater changes to HDL and Triglycerides (TG), than                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590773 -                  taking Atorvastatin in higher doses, e.g., 20 or 40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590774 -                  mg. ref SDS 46 CO56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
590776 -  ..
590777 - VA Progress Notes Plan continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590778 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590779 -            3.  Regarding medical trial- PCSK9 is not available at this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590780 -                time, but I will contact UCSF to determine if there are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590781 -                any ongoing trials for lipid lowering medications and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590782 -                see if Mr Welch could participate in any of them.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590784 -  ..
590785 - This implements discussion during the meeting today, on finding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590786 - clinical trial for PCSK9 to recover from atherosclerosis, without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590787 - using statins, shown above. ref SDS 0 1P5M, and as further cited in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590788 - the Progress Notes. ref SDS 0 Q17I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590790 -  ..
590791 - VA Progress Notes Plan continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590792 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590793 -            4.  Continue physical activity and low fat/low                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
590794 -                cholesterol diet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590796 -                 ..
590797 -            5.  RTC in 4 weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590798 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590799 -                   [On 131210 received letter from Doctor Alba asking about                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
590800 -                   progress taking Atorvastatin 40 mg, and requesting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590801 -                   submission of pending issues for next meeting. ref SDS 49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590802 -                   HY6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
590804 -                    ..
590805 -                   [On 131216 0028 letter to Doctor Alba and medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
590806 -                   team submits pending issues to discuss during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590807 -                   meeting on 131219, ref SDS 50 8N50, and lists                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
590808 -                   TG/HDL-C ratio and LDL-P issues. ref SDS 50 6T49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
590810 -             ..
590811 -        6.  Patient was discussed with Doctor Bikle                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590813 -         ..
590814 -   11.  Clinical Reminder Activity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
590815 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590816 -        MED REC NON PRIMARY CARE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
590818 -         ..
590819 -        Medication Reconciliation completed, including non-VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
590820 -        medications and descrepancies, if identified, were addressed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
590821 -        Medication, medication changes and importance of medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
590822 -        management were reviewed with the patient/caregiver.  An                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590823 -        updated list of reconciled medications have been provided to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
590824 -        the patient/caregiver.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
590836 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590837 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590838 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590839 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590840 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590841 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590842 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590843 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590844 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590845 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590846 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
590847 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
5909 -