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 -