CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
4803 -
4803 - ..
4804 - Summary/Objective
4805 -
480501 - Follow up ref SDS 16 0000. ref SDS 14 0000.
480502 -
480503 -
480504 -
480505 -
480506 -
480508 - ..
4806 -
4807 -
4808 - Progress
4809 -
480901 - Meeting with Doctor Sandhu, following prior review of primary care on
480902 - 130603 1300. ref SDS 16 PPVY
480903 -
480905 - ..
480906 - On being admitted into the examination area, Martha stopped us in the
480907 - hallway, to get a weight measurement on an electronic scale...
480908 -
480909 - Weight 182.
480911 - ..
480912 - Martha said she can give a flue shot before, or after the meeting
480913 - with Doctor Sandhu.
480915 - ..
480916 - Decided to get the flu shot immediately.
480918 - ..
480919 - Martha used a needle to inject flu vaccination in the upper left arm,
480920 - just below the shoulder.
480922 - ..
480923 - Martha took vitals...
480925 - ..
480926 - She said the clinic electronic equipment for taking vitals has not
480927 - been working correctly. She could not get the temperature equipment
480928 - to report anything. The blood pressure equipment also seemed to fail.
480930 - ..
480931 - She left the room and returned with another portable electronic
480932 - vitals recording unit. This reported
480933 -
480934 - BP 141 80,
480936 - ..
480937 - Temperature was taken with a forehead heat sensative equipment that
480938 - registered...
480939 -
480940 - Temp 97.8
480942 - ..
480943 - Explained blood pressure numbers seem very high, based on patient
480944 - history over past 3 years, most recently on 131206, shown in case
480945 - study on 120101 0900. ref SDS 4 NX7K
480947 - ..
480948 - Martha cross checked the electronic BP equipment results by using a
480949 - traditional handpump with cuff equipment she retrieved from a desk
480950 - drawer in the examination room.
480952 - ..
480953 - Martha said some patient bring with them documents showing patient
480954 - history of blood pressures taken at home.
480956 - ..
480957 - Explained patient history for vitals, medication, exercise and diet is
480958 - shown on the Internet in case study on 120101 0900. ref SDS 4 QJ5I
480960 - ..
480961 - Martha said there isn't enough time to check the record on patient
480962 - history.
480964 - ..
480965 - Advised it takes about 10 seconds to get patient history.
480967 - ..
480968 - Martha said there isn't enought time.
480970 - ..
480971 - We walked down the hallway to Doctor Sandhu's office.
480973 - ..
480974 - Doctor Sandhu previously reported that he started Lipitore to reduce
480975 - cholesterol, because his lipid numbers are 250 over 150, shown on
480976 - 130603 1300. ref SDS 16 PPVY
480978 - ..
480979 - Today he reported debilitating side effects taking Lipatore
480980 - (Atorvastatin). As a result, he has stopped taking all medications to
480981 - control cholesterol.
480983 - ..
480984 - He suffers back pain and chest pain, which prevent from walking any
480985 - distance, including from the parking lot to the VA office. During the
480986 - meeting today, the doctor had difficulty getting up from his chair and
480987 - walking to open the door just 4 feet away, for the patient to leave
480988 - the examination room.
480990 - ..
480991 - He has had 2 angiograms. The first was 5 years ago. The 2nd was more
480992 - recent, perhaps earlier this year. The recent angiogram showed his
480993 - arteries are too small for treatments with stents and/or heart bypass
480994 - surgery (cbag). He had to forego his annual visit to support a
480995 - medical clinic in India this year due to his own medical disabilities.
480997 - ..
480998 - The doctor discussed considering retirement. He might reduce his
480999 - work commitment to only 2 days per week.
481001 - ..
481002 - Doctor received the letter to the vA on 131125 0005. ref SDS 21 HY6O
481004 - ..
481005 - Doctor Sandhu reviewed the lab on 131015, and noted today that Total
481006 - Bilirubin is above the target range. He feels this does not present a
481007 - serious medical problem yet.
481009 - ..
481010 - The doctor scheduled follow up for next May or June 2014.
481012 - ..
481013 - Thanked Doctor Sandhu for providing excellent care the past 8 years,
481014 - beginning in 2005, reported on 050629 1000. ref SDS 1 HS5G
481015 -
481016 -
481017 -
4811 -
SUBJECTS
Default Null Subject Account for Blank Record
4903 -
490401 - ..
490402 - Medical Chart Progress Notes Meeting 131121 VA SF Medical Center
490403 -
490404 - Follow up ref SDS 20 NV6H, ref SDS 19 CY7I, ref SDS 18 TF5O.
490405 -
490406 - 1. LOCAL TITLE: Primary Care Scheduled Visit 60297
490407 - STANDARD TITLE: PRIMARY CARE NOTE
490408 - DATE OF NOTE: DEC 09, 2013 @ 080735
490409 - ENTRY DATE: DEC 09, 2013 @ 080735
490410 - AUTHOR: SANDHU, HARKESH S
490411 - EXP COSIGNER:
490412 - URGENCY:
490413 - STATUS: COMPLETED
490415 - ..
490416 - 68 yo MALE with medical problems as listed in problem list came
490417 - in for f/u. Pt is in endo/card clinic at VASF. Pt has been put
490418 - on lipitor 40mg for last 3 weeks and says he is so far doing ok
490419 - and is on omeprazole 40 mg. Pt has been trying to read up as
490420 - well on non statin medicines. Other than this he has been
490421 - doing well. No f/c/n/v/d. Computerized Problem List is the
490422 - source for the following:
490423 -
490424 - 1. Dizziness * (ICD-9-CM 780.4) 09/06/12 EGAN,JAMES
490425 - 2. Paresthesia * (ICD-9-CM 782.0) 09/06/12 EGAN,JAMES
490426 - 3. Vitamin D Deficiency 08/03/11 SANDHU,HARKESH
490427 - 4. Postsurgical Aortocoronary Bypass Status 03/09/11 EGAN,JAMES
490428 - (ICD-9-CM V45.81)
490429 - 5. Esophageal Stricture 03/05/10 LEE,RANDALL E
490430 - 6. Screening for Malignant Neoplasms of colon 11/15/11 LEE,RANDALL E
490431 - (ICD-9-CM V76.51)
490432 - 2010 colonoscopy: no polyp. Next screen 2020
490433 - 7. Coronary Atherosclerosis (unspecified type 02/02/10 LEE,RANDALL E
490434 - vessel, native or graft) (ICD-9-CM 41
490435 - 8. Coronary Artery Bypass using Venous and 01/04/10 SANDHU,HARKESH
490436 - Arterial Grafts (Single Vein Graft), Onset
490437 - 10/00/09
490438 - done at vasf
490439 - 9. Surgical Thoracoscopy with Esophagomyotomy 01/04/10 SANDHU,HARKESH
490440 - (Heller Type), Onset 12/16/09
490441 - at vasf
490442 - 10. Hyperlipidemia * (ICD-9-CM 272.4) 10/02/09 EGAN,JAMES
490443 - 11. Inflamed Seborrheic Keratosis (ICD-9-CM 03/12/07 LIN,BERTHA
490444 - 702.11)
490445 - 12. Rosacea * (ICD-9-CM 695.3) 03/12/07 LIN,BERTHA
490446 - 13. Dermatitis * (ICD-9-CM 692.9) 03/12/07 LIN,BERTHA
490447 - 14. Tinea Unguium * (ICD-9-CM 110.1) 03/12/07 LIN,BERTHA
490448 - 15. Tinea * (ICD-9-CM 110.9) 03/12/07 LIN,BERTHA
490449 - 16. Rosacea conjunctivitis (ICD-9-CM 372.31) 03/02/07 MARGULIES,LINDA
490450 - 17. Rosacea * (ICD-9-CM 695.3) 03/02/07 MARGULIES,LINDA
490451 - 18. Blepharitis NOS 02/21/07 MARGULIES,LINDA
490452 - 19. Achalasia * (ICD-9-CM 530.0) 12/22/05 SANDHU,HARKESH
490453 - 20. Abn. LFT's 08/16/05 SANDHU,HARKESH
490454 - 21. Obesity 06/29/05 SANDHU,HARKESH
490455 - 22. Rosacea 06/29/05 SANDHU,HARKESH
490456 - 23. Tinea Unguium 06/29/05 SANDHU,HARKESH
490458 - ..
490459 - 2. Active Outpatient Medications (excluding Supplies):
490460 -
490461 - 1. OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH ACTIVE
490462 - TWICE A DAY -15 MINUTES BEFORE MEALS FOR ACID
490463 - REFLUX
490465 - ..
490466 - Patient Comment...
490468 - ..
490469 - Atorvastatin 4-week trial was prescribed by VA SFMC on 131121 0930.
490470 - ref SDS 20 6H6K
490472 - ..
490473 - Patient history shows Atorvastatin 40 MG was started on 131121, shown
490474 - in case study on 120101 0900. ref SDS 4 RN3F
490476 - ..
490477 - Progress Notes Primary Care ASSESSMENT AND PLAN continue...
490478 -
490479 - 3. PE: [Physical Examination]
490480 -
490481 - 1. Most recent vitals:
490482 -
490483 - Temperature: 96.7 F [35.9 C] (11/15/2013 07:32)
490484 - Pulse: 68 (12/09/2013 07:58)
490485 - Respirations: 18 (12/09/2013 07:58)
490486 - B/P: 140/80 (12/09/2013 07:58)
490487 - Height: 66 in [167.6 cm] (11/15/2013 07:32)
490488 - Weight: 182 lb [82.7 kg] (12/09/2013 07:58)
490489 - BMI: 29.4
490490 - Pain: 0 (12/09/2013 07:58)
490491 - HEENT: nc, at, perrl,eomi,no dns,no wax and nl tm
490493 - ..
490494 - 2. LUNGS: clear to auscultation and percussion
490496 - ..
490497 - 3. CARDIAC: nl s1s2 no murmur,
490499 - ..
490500 - 4. ABDOMEN: Soft, nontender, BS active, no HSM, no masses
490502 - ..
490503 - 5. EXT: No cyanosis,clubbing or edema.
490505 - ..
490506 - 6. NEURO: alert and oriented x3 , cn 2 -12 intact and no gross
490507 - motor or sensory abnormality found
490509 - ..
490510 - 4. LABS:
490511 -
490512 - Collection DT Spec GLUCOSE BUN CREAT NA K CL CO2
490513 - 10/15/2013 08:25 PLASMA 108 24 0.83 139 4.3 105 27
490514 - 05/29/2013 08:18 PLASMA 120 H 18 0.83 139 4.9 H 105 30
490516 - ..
490517 - Collection DT Spec ALT AST ALK PHO ALBUMIN T. BIL
490518 - 10/15/2013 08:25 PLASM 17 20 84 3.9 1.7 H
490519 - 05/29/2013 08:18 PLASM 19 22 87 4.0 1.3 H
490521 - ..
490522 - Collection DT Spec WBC HGB HCT MCV MCHC PLT
490523 - 05/29/2013 08:18 BLOOD 7.4 15.0 46.2 90.7 32.5 279
490524 - 11/30/2012 10:01 BLOOD 7.5 14.5 43.9 90.3 33.0 254
490526 - ..
490527 - SCLU - TSH
490528 - Collection DT Spec Tsh
490529 - 10/15/2013 08:25 SERUM 2.62
490530 - 12/07/2010 09:17 SERUM 2.61
490532 - ..
490533 - Lab on 131015 has no evident entry for Tsh - could be labeled
490534 - differently. ref SDS 17 D26G
490535 -
490536 - [On 131219 0930 Progress Notes for meeting at VA in San
490537 - Francisco shows Tsh 2.6 for lab on 131015, similar to error
490538 - showing Tsh 2.62 for lab on 131015, indicated in these
490539 - progress notes on 131209. ref SDS 22 FJ6G
490541 - ..
490542 - Collection DT Spec CHOL TRIGLYC HDL LDL-CHO
490543 - 10/15/2013 08:25 PLASM 321 H 109 50 249 H
490544 - 05/29/2013 08:18 PLASM 307 H 85 50 240 H
490546 - ..
490547 - 5. ASSESSMENT AND PLAN:
490548 -
490549 - 1. Parasthesia : He has not had much difference.
490551 - ..
490552 - Patient Comment...
490554 - ..
490555 - Source for this status report on parasthesia is unclear in the record.
490556 - Case study on vitals, exercise, diet, and medications shows
490557 - significant reduction of peripheral neuropathy (parasthesia), since
490558 - ending Rosuvastatin 12 months ago on 121206, see the record dated,
490559 - 120101 0900. ref SDS 4 GC6N
490561 - ..
490562 - See comment on Progress Notes for meeting on 131121, presenting record
490563 - on peripheral neuropathy, also called numbness. ref SDS 20 E34O
490565 - ..
490566 - Progress Notes Primary Care ASSESSMENT AND PLAN continue...
490567 -
490568 - 2. HTN/CAD : Cont current meds. care per cardiology.
490570 - ..
490571 - 3. Hyperlip/obesity : care asper VASF clinic.
490573 - ..
490574 - 4. Heel pain / planter fascitis ; doing ok .
490576 - ..
490577 - 5. GERD : care per GI.
490579 - ..
490580 - 6. Call in may for f/u
490582 - ..
490583 - 7. Clinical Reminders:
490584 -
490585 - 1. Medication Reconciliation:
490586 -
490587 - No Changes To Medications:
490588 -
490589 - 1. The patient's current CPRS Medication List was
490590 - reviewed with Patient/Caregiver, and was found to
490591 - be correct and up to date.
490592 -
490593 - -no meds added
490594 - -no meds discontinued
490595 - -no meds changed
490596 - -no discrepancies noted
490598 - ..
490599 - 2. Patient/Caregiver has a reconciled medication
490600 - list.
490602 - ..
490603 - 3. The importance of managing personal medication
490604 - information was discussed w/ Patient/Caregiver:
490606 - ..
490607 - -carry medication list at all times, in the event
490608 - of emergency
490610 - ..
490611 - -update medication list when meds are added,
490612 - stopped, or changed
490614 - ..
490615 - -give a list to his/her primary care physician at
490616 - every visit and bring medication bottles if
490617 - possible
490619 - ..
490620 - 2. Assess Statin Use - Lipids (CVD/DM):
490621 -
490622 - The patient is currently on a moderate or high dose
490623 - statin.
490625 - ..
490626 - Patient Comment...
490628 - ..
490629 - This aligns with patient comment shown above. ref SDS 0 BS6I
490631 - ..
490632 - Progress Notes Primary Care ASSESSMENT AND PLAN continue...
490633 -
490637 -
490638 -
490639 -
490640 -
490641 -
490642 -
490643 -
490644 -
490645 -
490646 -
490647 -
490648 -
4907 -