CONTACTS
SUBJECTS
VA Prescribe Atorvastin 10 MG Trial 4 Weeks Evaluate Side Effects In
3903 -
3903 - ..
3904 - Summary/Objective
3905 -
390501 - Follow up ref SDS 50 0000. ref SDS 44 0000.
390502 -
390503 - Meeting VA San Francisco, ref SDS 0 195I, report good progress
390504 - lowering risks of recurrant CVD based on concordant low LDL-P 861 with
390505 - low LDL-C 81. shown by lab NMR lipid panal. ref SDS 0 TB6J Medical
390506 - team excellent results collaborating doctor/patient partnership.
390507 - ref SDS 0 1L7M Atorvastatin 40 mg started 131121, and then changed to
390508 - Atorvastatin 10 mg with Ezetimibe 10 mg started 131230. ref SDS 0 IE7F
390509 - No side effects taking medication past 6 weeks. ref SDS 0 333L
390510 - Objectives and ramifications of discordance between LDL-P and LDL-C
390511 - discussed. ref SDS 0 WM8J Regression of atherosclerosis plaque can be
390512 - assessed with CT and IVUS modalities to evaluate recovery from prior
390513 - acute condition that required surgery in 2009. ref SDS 0 JZ4O Will
390514 - continue medication, diet, exercise and weight loss protocols, and
390515 - test lipid panal again in 3 months on 140519 0800. ref SDS 0 8X5O Did
390516 - not discuss today elevated potasium and bilirubin. ref SDS 0 GT7G
390518 - ..
390519 - [On 140226 1243 letter to VA submits this record of meeting
390520 - on 140213, ref SDS 63 HY6O, and notifies cold/flu symptoms
390521 - began a week ago, similar to side effects for Atorvastatin
390522 - and Ezebimibe. ref SDS 63 JR8H Request consideration order
390523 - CT test evaluate regression of athersclorosis plaque.
390524 - ref SDS 63 JR99
390526 - ..
390527 - [On 140303 1644 letter requests submission of Progress
390528 - Notes for meeting on 140213. ref SDS 66 E792
390530 - ..
390531 - [On 140310 0939 received Progress Notes from VA for meeting
390532 - on 140213. ref SDS 70 VP9O
390533 -
390534 -
390535 -
390537 - ..
3906 -
3907 -
3908 - Background
3909 -
3910 -
391001 - Lab on 131015, showing LDL-C cholesterol remained high, 131015 0724,
391002 - ref SDS 38 BE6O, conflict with increased exercise and weight loss,
391003 - discussed in the letter to the medical team yesterday on 131016 1632.
391004 - ref SDS 39 IW57
391006 - ..
391007 - On 131017 1000 VA medical chart Progress Notes assessment report
391008 - patient status CAD stable, asymptomatic. hyperlipidemia not
391009 - controlled. ref SDS 40 T24N
391011 - ..
391012 - On 131017 1000 Doctor Egan proposed referring patient for clinical
391013 - trial to reduce cholesterol with new "targeted" drugs. ref SDS 40 179N
391015 - ..
391016 - On 131017 1000 VA medical chart Progress Notes assessment report
391017 - patient status hyperlipidemia not controlled, ref SDS 40 PSXT; Doctor
391018 - Egan makes referral to SF VA Medical Center for consult on
391019 - participation clinical trials, ref SDS 40 EU9F, with experimental
391020 - agents such as AMG 145 and REGN 727 to resolve multiple statin
391021 - intolerances. ref SDS 40 CN4H
391023 - ..
391024 - On 131103 received letter from VA SF Medical Center scheduling meeting
391025 - on 131121 1000, to consider clinical trial for lowering cholesteral.
391026 - ref SDS 41 YT4N
391028 - ..
391029 - On 131112 New York Times published several articles reporting that the
391030 - day before on 131113, American Heart Association published new
391031 - guidelines for treating CAD patients that expand use of statin
391032 - medication regardless of cholesterol levels, ref SDS 42 0001, and
391033 - further raise the LDL 70 to LDL 190, as a target for cardiovascular
391034 - risk. ref SDS 42 CW6H
391036 - ..
391037 - On 131114 New York Times published several articles reporting that the
391038 - day before on 131113, American Heart Association published new
391039 - guidelines for treating CAD patients. ref SDS 43 SH6G
391041 - ..
391042 - On 131121 0930 meeting with Doctor Alba at San Francisco Medical
391043 - Center - prescribed Atorvastatin 20 mg 4-week trial and evaluate
391044 - adding Zetia 10 mg, schedule follow up on 131219 0930. ref SDS 44 6H6K
391046 - ..
391047 - On 131121 1604 in another record later in the day, VA prescription RX
391048 - # 5674471 for Atorvastatin 20 mg was ordered. ref SDS 45 GH5M
391050 - ..
391051 - On 131125 0005 letter from Karen reports VA work plan to take statin
391052 - drug low dose Atvorstatin 10 mg for 4 weeks, then add ezetimibe
391053 - (Zetia) 10 mg in clinical trial for lowering cholesterol. ref SDS 46
391054 - V154
391056 - ..
391057 - On 131125 0005 research seems to indicate this clincial trial of low
391058 - dose Atorvasatatin 10 mg with Zeitia 10 mg has lowered cholesterol LDL
391059 - < 70, ref SDS 46 CO45; aligns with VA work plan, shown in VA Progress
391060 - Notes on 131121 0930. ref SDS 44 S26O
391062 - ..
391063 - On 131205 1448 received new prescription for Atvorstatin 20 mg,
391064 - ordered by Doctor Alba today for 4-week trial to assess side effects
391065 - for adding 2nd drug, Zetia 10 mg to lower LDL 249. ref SDS 47 GH5M
391067 - ..
391068 - On 131216 0028 letter to Doctor Alba submit agenda for meeting at VA
391069 - SFMC on 131219. ref SDS 49 HY6O
391071 - ..
391072 - On 131219 0930 meeting Doctor Alba at San Francisco VA Medical Center
391073 - ordered Ezetimibe 10 mg prescription for adding to Atorvastatin, and
391074 - ordered blood test to evaluate changes in lipid profile. 131219 0930,
391075 - ref SDS 50 NJ6G
391077 - ..
391078 - On 131230 1450, received Ezetimibe in US mail, ref SDS 51 5N3O,
391079 - ordered by Doctor Alba on 131219, 131219 0930, ref SDS 50 6H6K; begin
391080 - trial to manage cholesterol with Atorvastatin 10 mg and Ezetimibe 10
391081 - mg, planned during meeting at VA on 131121 0930. ref SDS 44 6H6K
391083 - ..
391084 - On 140114 0845 letter to Diana request Progress Notes meeting 131219,
391085 - ref SDS 52 HY6O, and ask about expanding scope pending lab to include
391086 - LDL-P. ref SDS 52 2140
391088 - ..
391089 - On 140115 1842 letter Diana will look for Progress Notes meeting
391090 - 131219, ref SDS 53 HY6O; investigating prospects for ordering lab test
391091 - LDL-P, ref SDS 53 CE80; VA claims patient cholesterol and LDL are above
391092 - target. ref SDS 53 CE91 VA further claims testing LDL-P not effective
391093 - in this case because LDL-C is not optimal. ref SDS 53 FF4H
391095 - ..
391096 - On 140116 0814 letter thanks Doctor Alba for investigting to find
391097 - Progress Notes for meeting at VA on 131219. ref SDS 54 HY6O Cite
391098 - research indicating patient with discordant LDL-C high and LDL-P low,
391099 - shown in patient lab on 131015, constitutes least risk for
391100 - arterialsclorosis disorder, CVD, mycardial infarction. ref SDS 54 735Y
391102 - ..
391103 - On 140128 1327 letter asks again about Progress Notes meeting 131219,
391104 - ref SDS 55 HY6O; report hiking 11 miles per day continued, weight hit
391105 - 165, ref SDS 55 TZ8U; ask where to get lab at VA Martinez, in San
391106 - Francisco, or at UCSF. ref SDS 55 TZ96 No side effects from
391107 - Atorvastatin and Ezetimibe. ref SDS 55 TZ99
391109 - ..
391110 - On 140131 0815 have not received instructions from VA on getting lab
391111 - to test LDL-P, so ordered test. ref SDS 56 OO5G lab blood draw at
391112 - Labcorp in Walnut Creek on Ygnacio Valley Road. ref SDS 56 NT6T
391114 - ..
391115 - On 140201 1159 obtained blood draw for Lipid NMR test at Labcor on
391116 - Health Testing Centers order # 27716, ref SDS 57 KQ4L, showing
391117 - "concordance" LDL-P 861, LDL-C 81, HDL 61, TG 68, LDL (pattern A) size
391118 - = large bouyant protective. ref SDS 57 IM9N
391120 - ..
391121 - On 140203 1147 since have not received instructions from VA, obtained
391122 - blood draw at VA in Martinez to cross check Labcorp blood test. 140203
391123 - 1147, ref SDS 58 KK9M, showing LDL-C 93, HDL 58, TG 47, ref SDS 58
391124 - IM9N, indicating "concordance" LDL-P 626, LDL (pattern A) size = large
391125 - bouyant protective. ref SDS 58 QV5G
391127 - ..
391128 - On 140204 1236 letter from VA today, notifies that Progress Notes for
391129 - meeting on 131219, have been posted and are available for customer to
391130 - receive from ROI department. ref SDS 60 HY6O Cause for 6-weeks delay
391131 - issuing Progress Notes not clear in the record. ref SDS 60 V44F VA
391132 - Progress Notes for meeting on 131219, are comprehensive and helpful.
391133 - ref SDS 60 MR3G Progress Notes have many minor grammatical errors
391134 - likely due to limited time, ref SDS 60 MZ5H, VA does not support NMR
391135 - lipid tests to determine LDL-P and discordance with LDL-C; patient can
391136 - obtain test from another lab. ref SDS 60 CE80 VA letter today
391137 - maintains discordance with low LDL-P and high LDL-C is "unhealthy" -
391138 - submits no evidence from medical literature supporting this
391139 - proposition, nor to address literature submitted to the VA stating
391140 - discordance is the healthiest condition for CVD patients. ref SDS 60
391141 - 6U4L VA concurs that lowering weight toward BMI standards aids
391142 - resolving hyperlipidemia. ref SDS 60 8N9H VA maintains lifestyle
391143 - through exercise and diet to control weight and hyperlipidemia require
391144 - support taking statin medications, e.g., Atorvastatin and Ezetimibe.
391145 - ref SDS 60 GT5F VA letter today says patient mis-reads literature on
391146 - discordance between LDL-P and LDL-C, and proposes discussions to
391147 - clarify this matter during meeting scheduled on 140213. ref SDS 60 HU5M
391148 - VA prefers patient get labs drawn at San Francisco VA Medical Center.
391149 - ref SDS 60 PT3M
391151 - ..
391152 - On 140213 0830 meeting VA San Francisco, ref SDS 0 195I, report good
391153 - progress lowering risks of recurrant CVD based on concordant low LDL-P
391154 - 861 with low LDL-C 81. shown by lab NMR lipid panal. ref SDS 0 TB6J
391155 - Medical team excellent results collaborating doctor/patient
391156 - partnership. ref SDS 0 1L7M Atorvastatin 40 mg started 131121, and
391157 - then changed to Atorvastatin 10 mg with Ezetimibe 10 mg started
391158 - 131230. ref SDS 0 IE7F No side effects taking medication past 6
391159 - weeks. ref SDS 0 333L Objectives and ramifications of discordance
391160 - between LDL-P and LDL-C discussed. ref SDS 0 WM8J Regression of
391161 - atherosclerosis plaque can be assessed with CT and IVUS modalities to
391162 - evaluate recovery from prior acute condition that required surgery in
391163 - 2009. ref SDS 0 JZ4O Will continue medication, diet, exercise and
391164 - weight loss protocols, and test lipid panal again in 3 months on
391165 - 140519 0800. ref SDS 0 8X5O Did not discuss today elevated potasium
391166 - and bilirubin. ref SDS 0 GT7G
391167 -
391168 -
391169 -
391170 -
391172 - ..
3912 -
3913 -
3914 - Progress
3915 -
391501 - Hyperlipidemia Cholesterol Controlled Exercise Diet Medication
391502 - Cholesterol Managed Clinical Trial Exercise Diet Medication
391503 - VA Excellent Health Care Aligns Lipid Panel with Good Health Ranges
391504 -
391505 - Follow up ref SDS 50 HY6O, ref SDS 44 HY6O.
391507 - ..
391508 - Review agenda presented in letter to VA on 140211 0133. ref SDS 61
391509 - HY6O
391510 -
391511 - 1. Thanked the VA for completing Progress Notes on prior
391512 - meeting held in December on 131219, received a few days
391513 - after the VA letter on 140204 1236. ref SDS 60 HY6O
391514 - Alignment in Progress Notes with patient record for the
391515 - meeting shows good communication for doctor/patient
391516 - partnership. ref SDS 50 NJ6G
391518 - ..
391519 - 2. VA can follow patient history medications, diet, exercise,
391520 - vitals, with correlation to labs, shown in case study on
391521 - 120101 0900. ref SDS 11 LJ6H This was previously noted in
391522 - a letter to the VA on 131216 0028. ref SDS 49 8N53
391524 - ..
391525 - 3. On entering the examination room, the doctor had already
391526 - opened the electronic letter with the agenda for meeting
391527 - today, dated 2 days ago on 140211 0133, ref SDS 61 HY6O,
391528 - and had further opened the link in the letter to display on
391529 - her computer screen the consolidated lab report comparing
391530 - NMR test results on 140201, with VA Lab performed 2 days
391531 - later on 140203 1147. ref SDS 58 U45J
391532 -
391533 - [On 140226 1243 letter to VA submits this record of
391534 - meeting on 140213, ref SDS 63 HY6O, and notifies
391535 - cold/flu symptoms began a week ago, similar to side
391536 - effects for Atorvastatin and Ezebimibe. ref SDS 63 JR8H
391537 - Request consideration order CT test evaluate regression
391538 - of athersclorosis plaque. ref SDS 63 JR99
391539 -
391540 -
3916 -
SUBJECTS
Default Null Subject Account for Blank Record
4003 -
400401 - ..
400402 - 4. Doctor Alba was pleased with strong results showing low
400403 - LDL-P 861 < 1000 and concordance with low LDL-C 81 < 100,
400404 - ref SDS 58 U45J, cited in para 5 of the agenda on 140211
400405 - 0133. ref SDS 61 TV3M
400407 - ..
400408 - HDL 61 aligns with sharp decline in triglycerides 47,
400409 - commonly associated with extended exercise, here hiking 933
400410 - miles since the prior lab on 131015. HDL > 60 supports
400411 - regression of atherosclerosis plaque from extended exercise
400412 - that also increases EPCs to repair endothelial lesions,
400413 - cited in research on 131125 0005, ref SDS 46 6O9M and
400414 - further at ref SDS 46 R44O
400416 - ..
400417 - Work plan might strive for continuing extended exercise
400418 - that lowers LDL-P < 700, based on studies indicating this
400419 - is a common bench mark for minimal CVD risk, cited in
400420 - research on 131125 0005. ref SDS 46 WY9H
400422 - ..
400423 - Medical team has done excellent work collaborating through
400424 - doctor/patient partnership aligning lipid panel with
400425 - healthy blood pressure and heart rate profiles derived from
400426 - medication, diet, exercise and weight loss, since prior lab
400427 - on 131015, shown in case study on 120101 0900. ref SDS 11
400428 - YU5J VA's outstanding care was noted in the letter on
400429 - 140211 0133. ref SDS 61 TV53
400431 - ..
400432 - 4. The doctor asked when Atorvastatin and Ezetimibe were
400433 - started that helped accomplish favorable lab results on
400434 - 140203? ref SDS 58 U45J
400436 - ..
400437 - Notes for the lab on 140203, saying Atorvastatin 40 mg
400438 - started on 131121, and Atorvastatin 10 mg with Ezetimibe 10
400439 - mg was started on 131230. (see para f and g on 140203 1147,
400440 - ref SDS 58 LO4N, citing case study documenting diet,
400441 - exercise, vitals, and medication shown on 120101 0900,
400442 - ref SDS 11 RN3F, and further at ref SDS 11 6A6H
400444 - ..
400445 - The doctor said patient verbal memory is accurate enough,
400446 - since it takes time to navigate complex patient history
400447 - with links for precision access in the record. Patient
400448 - offered to navigate the VA's computer to the link showing
400449 - the actual record on starting medication. It only takes a
400450 - few seconds. The doctor requested verbal representation
400451 - from memory to save time.
400453 - ..
400454 - The patient recalled that Atorvastatin 10 mg with Ezetimibe
400455 - 10 mg started OA 131230, based having written and reviewed
400456 - this record recently. The doctor wrote this date with an
400457 - ink pen on paper from printing results for the VA lab on
400458 - 140203, rather than rely on the actual record of events.
400459 -
400460 -
400461 -
4005 -
SUBJECTS
Default Null Subject Account for Blank Record
4103 -
410401 - ..
410402 - 5. Side effects taking Atorvastatin 10 mg and Ezetimibe 10 mg?
410404 - ..
410405 - Common side effects caused by Atorvastatin are listed on
410406 - 130603 0930. ref SDS 33 PC6O
410408 - ..
410409 - Common side effects taking Ezetimibe 10 mg are listed on
410410 - 131125 0005. ref SDS 46 GD8G
410412 - ..
410413 - These lists have many common medical maladies, suggesting
410414 - potential for compounding mild side effects into serious
410415 - symptoms. VA's prescription for low dose of medications
410416 - mitigates this risk so far.
410418 - ..
410419 - The letter on 140128, to the VA reports no evident side
410420 - effects. ref SDS 55 TZ99 During the meeting today, the
410421 - patient cited no evident side effects since the letter on
410422 - 140128.
410423 -
410424 - [On 140225 possible side effects similar to cold/flu
410425 - symptoms reported for 2 weeks following meeting at VA on
410426 - 140213; subsidence during day and increase in severity
410427 - following Atorvastatin 10 mg and Ezetimibe 10 mg OA
410428 - 1900, may indicate accumulating effects of low dose
410429 - medications, see case study on 120101 0900. ref SDS 11
410430 - WB6F
410432 - ..
410433 - [On 140226 1243 letter to VA notifies cold/flu symptoms
410434 - began a week ago, similar to side effects for
410435 - Atorvastatin and Ezebimibe. ref SDS 63 JR8H
410437 - ..
410438 - The record so far of minimal side effects taking
410439 - Atorvastatin 10 mg and Ezetimibe 10 mg, significantly
410440 - improves on prior statin regimen taking Rosuvastating which
410441 - caused frequent urination from liver damage, that resulted
410442 - in severe dehydration, presented during the prior meeting
410443 - on 131121 0930. ref SDS 44 WK3I
410444 -
410445 -
410446 -
410447 -
410448 -
410449 -
4105 -
SUBJECTS
Default Null Subject Account for Blank Record
4203 -
420401 - ..
420402 - 5. Discordance reviewed.
420403 -
420404 - Discussed increasing medication to lower LDL-C 81 in
420405 - Labcorp test, and LDL-C 93 in VA test, presented on 140203
420406 - 1147. ref SDS 58 5C7M This proposal aligns with VA letters
420407 - on 140204 1236, ref SDS 60 GT5F, and on 140115 1842,
420408 - ref SDS 53 FF4H, and further with Progress Notes for
420409 - meeting at VA on 131219 0930. ref SDS 50 GO35 VA's letter
420410 - on 140204, seemed to indicate measuring LDL-P is
420411 - unnecessary, ref SDS 60 W66G, and saying elevated LDL-C 249
420412 - in lab on 131015, is "unhealthy," regardless of discordance
420413 - with low LDL-P. ref SDS 60 6U4L
420415 - ..
420416 - [On 140430 0900 follow up, ref SDS 73 265F
420418 - ..
420419 - The doctor explained increasing medication might resolve
420420 - existing plaque that has built up over the past year caused
420421 - by elevated cholesterol levels, shown in prior labs, listed
420422 - in patient history on 140203 1147. ref SDS 58 W25L
420423 -
420424 - [...below on 140213 0830 discuss CT and related testing
420425 - to evaluate regression of atherosclerosis plaque.
420426 - ref SDS 0 JZ4O
420428 - ..
420429 - Reviewed the record indicating existing cholesterol plaque
420430 - buildup can be resolved through increased exericse that
420431 - stimulates liver to increase HDL, and stimulates bone
420432 - marrow to produce more endothelial projenitor cells (EPCs)
420433 - that together drive regression of atherosclerosis,
420434 - indicated in research on 131125 0005. ref SDS 46 FV5L
420436 - ..
420437 - Reviewed correspondence citing medical literature showing
420438 - studies that suggest when high LDL-C is discordant with low
420439 - LDL-P risk of CVD is lower than concordance, with LDL-P and
420440 - LDL-C both low, shown in the record on 131125 0005.
420441 - ref SDS 46 FI3G This point was cited in prior
420442 - correspondence on 131216 0028. ref SDS 49 6T60 It was
420443 - discussed previously with VA during the meeting on 131219
420444 - 0930, ref SDS 50 GW8K, and as shown in Progress Notes
420445 - stating that LDL-P has the strongest association with CVD
420446 - risk, prepared for the same meeting on 131219 0930,
420447 - ref SDS 50 GO35 The letter to VA on 140116, presented
420448 - medical literature again, ref SDS 54 H29T, and expressly
420449 - shows this language...
420450 -
420451 - [...below on 140213 0830 Doctor Alba's Progress Notes
420452 - repreat prior notice that LDL-P has stronger
420453 - association with CVD risk than LDL-C. ref SDS 0 S35H
420454 -
420455 - "The highest risk and lowest risk groups are those with
420456 - discordant LDL-C and LDL-P. The high risk group has
420457 - high LDL-P and low LDL-C, while the lowest risk group
420458 - has high LDL-C with low LDL-P. Only a minority of
420459 - physicians would know that there is a segment of the
420460 - population with elevated LDL-C who are at low risk!
420461 - The same conclusion will be drawn from the next study."
420463 - ..
420464 - Today, the doctor requested assistance to find this
420465 - citation in patient medical records. The patient took
420466 - brief control of the computer in the Examination room and
420467 - navigated from the lab on 140203, displayed on the computer
420468 - screen. ref SDS 58 U45J Scrolled down to Analysis para 1
420469 - which has a link to the relevant research set out on
420470 - 131125. ref SDS 46 FI3G
420471 -
420472 - [...below on 140213 0830 VA Progress Notes present
420473 - discussion of this research but fail to show the
420474 - express finding that low LDL-P and elevated LDL-C is
420475 - the lowest risk for CVD, and that high LDL-P and low
420476 - LDL-C is a condition of highest CVD risk. ref SDS 0
420477 - I35L
420479 - ..
420480 - [On 140519 0800 meeting at the VA Doctor Alba pleased
420481 - LDL-P 851 declined, further below published guidance
420482 - that signals very healthy cholesterol levels, that
420483 - lowers CVD risk. ref SDS 77 X59G Reviewed research
420484 - again showing low LDL-P and high LDL-C present lowest
420485 - risk of CVD. ref SDS 77 T97N
420487 - ..
420488 - Doctor Alba requested the citation for this quoted text
420489 - from published medical literature.
420491 - ..
420492 - Explained all references to outside sources are listed in
420493 - the record at the beginning where a source initially
420494 - appears, so scrolling to the top of the article in this
420495 - case shows...
420497 - ..
420498 - Why is it necessary to measure LDL-P, instead of just LDL-C?
420499 -
420500 - http://eatingacademy.com/nutrition/the-straight-dope-on-cholesterol-part-vi
420501 -
420502 - By: Peter Attia, MD
420503 -
420504 - Peter Attia, M.D., is the co-founder and President of
420505 - the Nutrition Science Initiative (NuSI), a non-profit
420506 - based in San Diego, CA. He received his B.Sc. from
420507 - Queen's University in Canada and his M.D. from Stanford
420508 - Medical School in California. After his surgical
420509 - residency in general surgery at Johns Hopkins he worked
420510 - as a consultant at McKinsey & Company. He founded NuSI
420511 - with scientific journalist Gary Taubes in 2012.
420513 - ..
420514 - 5. Doctor Alba left the examination room to review the case
420515 - with Doctor Feingold, attending.
420517 - ..
420518 - 6. Doctor Feingold and Doctor Alba returned about 20 minutes
420519 - later.
420521 - ..
420522 - Background on Doctor Feingold is reported at UCSF...
420523 -
420524 - http://endocrine.ucsf.edu/faculty/faculty_profiles.html?key=aac3fd984e8df23112e53195167360aa&name=FEINGOLD%2CKENNETH+R
420526 - ..
420527 - 7. Discordance was further discussed...
420528 -
420529 - Doctor Feingold did not change the representation in VA
420530 - Progress Notes for the meeting on 131219, that says in
420531 - part... LDL-P has a stronger association than LDL-C with
420532 - cardiovascular risk. ref SDS 50 GO35
420534 - ..
420535 - Doctor Feingold seemed to suggest that measuring LDL-P does
420536 - not have medical value (i.e., is unnecessary) for patient
420537 - care, e.g., prescribing treatment, because LDL-P can be
420538 - assumed from TG/HDL ratio.
420540 - ..
420541 - Research on 131125 cited LDL-P correlation with TG/HDL
420542 - ratio. ref SDS 46 666G and ref SDS 46 338N Pub-med article
420543 - maintains small, dense LDL particle size represents
420544 - elevated CVD risk, and that TG/HDL ratio can substitute for
420545 - assuming particle size in the absence of direct
420546 - measurement. Pub-med article concluded TG/HDL-C ratio
420547 - higher than 0.9 is beneficial for assessing the presence of
420548 - small LDL - < 25.5 nm. ref SDS 46 VR5N Patient NMR lipid
420549 - lab performed by Labcorp on 140201, shows TG/HDL ratio
420550 - 68/61 = 1.1; VA lipid lab on 140203, shows 47/58 = 0.81.
420551 - 140203 1147. ref SDS 58 5C7M VA results align with NMR
420552 - test that found patient LDL particle size meets criteria
420553 - for "large pattern A," with negligible (< 90) small-size
420554 - particles. ref SDS 58 4W4T
420556 - ..
420557 - There was not enough time during the meeting today to
420558 - review this correlation, as a straight line calculation
420559 - that can "assume" LDL-P 626 from the VA lab on 140203 1147.
420560 - ref SDS 58 4Z66 Progress Notes for the meeting today, can
420561 - clarify this issue.
420563 - ..
420564 - Doctor Feingold cautioned against reliance on discordance
420565 - with low LDL-P < 700 and high LDL-C > 160, for large
420566 - "pattern A" LDL particles to protect against advance of
420567 - CVD, which is cited in research presented by Doctor Attia
420568 - and others shown on 131125 0005. ref SDS 46 OQ9N The
420569 - doctor seemed to indicate that discordance is very rare.
420571 - ..
420572 - Research on 131125 cites frequency of discordance in one
420573 - (1) study was about 20%, ref SDS 46 7G5L, and further notes
420574 - wide disparity among cardiologists on managing lipids to
420575 - reduce CVD risk. ref SDS 46 FI3G and ref SDS 46 OQ4W
420577 - ..
420578 - Doctor Feingold further explained today, that the
420579 - difference between LDL particle size A and size B is
420580 - "small." Therefore, even though patient's NMR lab test on
420581 - 140201 shows LDL particle size fits criteria for "healthy"
420582 - - i.e., "large" pattern A, 140201 1159, ref SDS 57 5C86,
420583 - rather than protect against penetration of the endothelial
420584 - lining, high LDL-C > 160 represents elevated risk for CVD.
420586 - ..
420587 - Recent guidance issued by AHA increasing goals for LDL-C to
420588 - 190, further complicates the picture, reported on 131112
420589 - 1422. ref SDS 42 CW6H LDL-P < 1000 and LDl-C < 190 could
420590 - fit the discordance model, but is not expressly mentioned
420591 - in the new report. Doctor Feingold seemed to indicate
420592 - during the meeting today, that the AHA guidelines are still
420593 - under review.
420595 - ..
420596 - Doctor Alba will look for medical literature on studies
420597 - that clarify the discordance issue, and cite them in
420598 - Progress Notes for the meeting today.
420599 -
420600 -
420601 -
4207 -
SUBJECTS
Default Null Subject Account for Blank Record
4303 -
430401 - ..
430402 - 8. Regression of athersclerosis lesions
430403 -
430404 - Blockages in arteries which required CABG +4 nearly 5 years
430405 - ago on 091022, ref SDS 3 PQWU, can be prevented and
430406 - resolved through endurance exercise that raises HDL to
430407 - cause regression of plaques, reported in research on 131125
430408 - 0005, ref SDS 46 E13K, and further with increasing EPC also
430409 - by endurance exercise. ref SDS 46 6O9M
430411 - ..
430412 - There is concern that elevated LDL-C the past year, shown
430413 - in lipid profile on 140203 1147, ref SDS 58 W25L, may have
430414 - caused atherosclerosis plaque to progress, as discussed
430415 - earlier in the meeting today, above. ref SDS 0 LQ6L The
430416 - same dataset showing elevated HDL and low TG over the same
430417 - period may suggest discordance causing substantial
430418 - regression of plaque.
430420 - ..
430421 - Life saving regression or threat from atherosclerosis
430422 - progression of plaque can be measured with CT tests,
430423 - reported on 131125 0005. ref SDS 46 N73K Related
430424 - modalities include Coronary computed tomography angiography
430425 - (CTA also CCTA) intravascular ultrasonography (IVUS),
430426 - near-infrared spectroscopy (NIRS), optical coherence
430427 - tomography (OCT), and thin-cap fibroatheroma (TCFA).
430428 - ref SDS 46 VW40
430430 - ..
430431 - VA ordered CT test last year on 130117, ref SDS 26 OH6G, to
430432 - evaluate recovery from achalasia following treatment with
430433 - Heller Myotomy surgery 4 years ago in 2009, and after
430434 - several years of pneumatic dilations. A few days later,
430435 - Doctor Stewart in General Surgery, found CT tests showed
430436 - remarkable recovery, reported in the record on 130122 1330.
430437 - ref SDS 27 03H6 These findings supported reduced
430438 - treatment.
430440 - ..
430441 - Similar findings from CT [...CCTA...] testing for
430442 - atherosclerosis might further guide treatment for CVD.
430443 -
430444 - [On 140226 1243 letter to VA request consideration in
430445 - Progress Notes to order CT test evaluate regression of
430446 - athersclorosis plaque. ref SDS 63 JR99
430448 - ..
430449 - [On 140305 1117 letter to VA follows up asking about
430450 - work plan in Progress Notes doing CTA and other testing
430451 - to evaluate regression of atheroscleroisis, ref SDS 67
430452 - WY3X, since CABG x4 surgery on 091022 0700. ref SDS 3
430453 - PQWU
430455 - ..
430456 - [On 140312 1720 letter to VA asks about adding
430457 - consideration in Progress Notes of CT and other image
430458 - testing to evaluate regression of atherosclerosis plaque
430459 - after significant increase in LDL-C in lab last year on
430460 - 131015. ref SDS 72 PSXX
430462 - ..
430463 - [On 140519 0800 follow up meeting with Doctor Alba;
430464 - attending physician Doctor Feingold advised that complex
430465 - anatomy of blood vessels intertwined by CABG surgery
430466 - prevents radiology analysts from reading CCTA scan tests
430467 - to evaluate regression of atherosclerosis. ref SDS 78
430468 - J83H
430470 - ..
430471 - [On 151019 0930 CCTA with calcium score performed;
430472 - meeting with doctor in Radiology Department reviewed
430473 - requirements for calcium score to evaluate response to
430474 - treatment recovering from atherosclorosis. ref SDS 82
430475 - GR4K At the end of the meeting, the doctor agreed to
430476 - perform calcium score for comprehensive CCTA test.
430477 - ref SDS 82 LQ5F However, analyst's report merely says
430478 - "All the bypass grafts are patent." ref SDS 82 JW8O
430480 - ..
430481 - [On 151019 0930 addendum received on 160113, and issued
430482 - by Doctor Priyanka Jha reports finding no evidence of
430483 - atherosclerosis plaque in active coronary circulatory
430484 - system, or words to that effect. ref SDS 82 QW5F
430485 -
430486 -
430487 -
430488 -
430489 -
430490 -
430491 -
430492 -
4305 -
SUBJECTS
Default Null Subject Account for Blank Record
4403 -
440401 - ..
440402 - 8. Prognosis and Protocols.
440403 -
440404 - Doctor Alba and Doctor Feingold indicated that losing
440405 - weight with diet control and exercise hitting 165 pounds on
440406 - 140121, again on 140129, and next day on 140130, reported
440407 - in patient history case study on 120101 0900, ref SDS 11
440408 - A39H, aligns with goals for managing cholesterol. As well,
440409 - they noted that hiking 933 miles the past 4 months, and
440410 - diet shown in patient history from case study on 120101
440411 - 0900, ref SDS 11 LO5O, further align with planning in the
440412 - prior meeting on 131219 0930, ref SDS 50 A56N, and in the
440413 - Progress Notes. ref SDS 50 F56N Research indicates
440414 - exercise and diet are factors in lowering triglycerides (TG
440415 - 68 in NMR test, and 47 in VA lab), and raising HDL 61 in
440416 - NMR and 58 in VA lab, which together lower LDL-P, reported
440417 - on 131125 0005. ref SDS 46 8X4N
440419 - ..
440420 - Medical team feels CCTA is not useful for patients to
440421 - evaluate recovery from atherosclerosis, established in this
440422 - case by history of CAGB x4 on 091022, for lowering statin
440423 - medications in order to reduce side effects, because
440424 - standard of care for atherosclerosis assumes patients
440425 - cannot recover; accepted practice is to maintain statin
440426 - treatments in order to slow the rate of progression.
440428 - ..
440429 - There was consideration to increase medication in order to
440430 - prevent atherosclerosis plaque from increasing?
440432 - ..
440433 - Decided to continue current dose of Atorvastatin 10 mg and
440434 - Ezetimibe 10 mg, and to maintain level of effort hiking 11
440435 - miles per day, 300 miles per month, since it appears
440436 - extended endurance exercise in this case has elevated HDL
440437 - 30 to HDL 61, required to rapidly regress atherosclerosis
440438 - plaque, reported in research on 131125 0005. ref SDS 46
440439 - E13K
440440 -
440441 - [...below on 140213 0830 Doctor Alba's Progress Notes
440442 - reflect understandings from these discussions during the
440443 - meeting today prescribing continued extended endurance
440444 - exercise to increase HDL that regresses atherosclerosis
440445 - plaque. ref SDS 0 E34O
440447 - ..
440448 - [On 140519 0800 follow up lab shows HDL 65 increased
440449 - from HDL 61, reflects implementation and success of
440450 - Doctor Alba's prescription to continue extended
440451 - endurance exercise. ref SDS 77 MY7J
440453 - ..
440454 - Evaluate protocols with labs in 3 months.
440456 - ..
440457 - Doing another NMR with VA lab can shed more light on how to
440458 - "assume" LDL-P calculated from TG and HDL, discussed by
440459 - Doctor Feingold, above. ref SDS 0 WQ8L
440460 -
440461 -
4405 -
SUBJECTS
Default Null Subject Account for Blank Record
4503 -
450401 - ..
450402 - 8. Doctor Alba issued documentation ordering follow up
450403 - meeting in May.
450405 - ..
450406 - Scheduled next meeting on 140519 0800.
450407 -
450408 -
450409 -
4505 -
SUBJECTS
Default Null Subject Account for Blank Record
4603 -
460401 - ..
460402 - 8. There was not enough time today, for discussing VA lab
460403 - showing potasium (K 5.4) is elevated again in the
460404 - Electrolytes panel, shown on 140203 1147. ref SDS 58 ZG5O
460405 - This was cited previously by Doctor Egan in Cardiology at
460406 - VA in Martinez, on 121206 0900. ref SDS 23 6K56
460408 - ..
460409 - T Bilirubin 2.1 further increased again, while Labcorp
460410 - shows both potasium and bilirubin are stable. ref SDS 59
460411 - ZG5O These matters in the agenda for the meeting today,
460412 - and submitted on 140211 0133, ref SDS 61 TV5F, can be
460413 - addressed in Progress Notes for the meeting today.
460414 -
460415 - [On 140430 0900 letter from Doctor Egan, Cardiology
460416 - Physician at Martinez Clinic, notes medical team did not
460417 - address elevated potassium in labs, and again notifies
460418 - that this condition represents exposure to "electrical
460419 - problems" with the heart. ref SDS 74 UV5I
460421 - ..
460422 - [On 140505 0936 Doctor Egan notified that medical team
460423 - at VA Medical Center in San Francisco was advised of
460424 - concerns on elevated potassium (K) and Total Bilirubin,
460425 - ref SDS 75 YV4L, shown in labs reported in the record on
460426 - 140203 1147. ref SDS 59 ZG5O
460428 - ..
460429 - [On 140508 1133 follow up lab by Labcorp shows potassium
460430 - (K) 5.6 elevated above range. ref SDS 76 ZG5O
460432 - ..
460433 - [On 140508 1133 follow up lab by Labcorp shows Total
460434 - Bilirubin 1.3 elevated, but improved only slightly above
460435 - range. ref SDS 76 015M
460436 -
460437 -
460438 -
460439 -
460440 -
460441 -
460442 -
4605 -
SUBJECTS
Default Null Subject Account for Blank Record
4703 -
470401 - ..
470402 - Medical Chart Progress Notes Meeting 140213 VA SF Medical Center
470403 -
470404 - Follow up ref SDS 50 476K, ref SDS 44 NV6H.
470405 -
470406 - [On 140303 1644 letter requests submission of Progress
470407 - Notes for meeting on 140213. ref SDS 66 E792
470409 - ..
470410 - [On 140305 1117 VA reports Progress Notes for meeting on
470411 - 140213, will be available for customer to review by end of
470412 - week. ref SDS 67 GO9N
470414 - ..
470415 - [On 140307 1509 letter asks about Progress Notes.
470416 - ref SDS 68 5X69
470418 - ..
470419 - [On 140308 0956 VA letter reports customer should have
470420 - received submission of Progress Notes for meeting on
470421 - 140213, via VA system email, if customer is "set up."
470422 - ref SDS 69 5N3O
470424 - ..
470425 - 1. LOCAL TITLE: ENDOCRINE-METABOLISM CLINIC F/U (MED)
470426 - STANDARD TITLE: ENDOCRINOLOGY OUTPATITNE NOTE
470427 - DATE OF NOTE: FEB 13, 2014 @ 1604
470428 - ENTRY DATE: FEB 22, 2014 @160739
470430 - EXP COSIGNER:
470431 - URGENCY:
470432 - STATUS: COMPLETED
470433 -
470434 - ***ENDOCRINE-METABOLISM CLINIC F/U (MED) Has ADDENDA***
470436 - ..
470437 - [On 140310 0939 received Progress Notes from VA for meeting
470438 - on 140213. ref SDS 70 VP9O
470440 - ..
470441 - [On 140312 1720 submitted comments on Progress Notes,
470442 - requesting document identification data, and submitting
470443 - comments. ref SDS 71 5N3O
470449 - ..
470450 - CC: follow up for high cholesterol
470452 - ..
470453 - 2. HPI
470454 -
470455 - 1. 68 year old male with history of CAD, s/p CABG in 2009,
470456 - Hyperlipidemia, achalasia, s/p lap heller myotomy and
470457 - fundoplication in 2009, who was referred by his Cardiologist,
470458 - Doctor Egan for management of hyperlipidemia.
470460 - ..
470461 - 2. He was last seen in endocrine clinic December 2013. On our
470462 - last appointment patient was started on Zetia 10 mg po
470463 - daily and continued Atorvastatin 10 mg daily- Patient
470464 - complained of cold like/flu symptoms that have now
470465 - improved. He continues to hike and follow a very active
470466 - lifestyle.
470468 - ..
470469 - VA's record here stating patient continues to hike and follow a very
470470 - active lifestyle," may not reflect patient exercise lowering
470471 - cardiovascular risk hiking 11 miles per day 7 days per week, beginning
470472 - OA 130417, shown in case study on 120101 0900, ref SDS 11 F35N, and
470473 - cited in letter to VA on 131125 0005, ref SDS 46 UK7K, and more recent
470474 - letter on 131216 0028. ref SDS 49 6T49 The letter on 131216,
470475 - expressly referenced case study that can be bookmarked for easy access
470476 - to track daily hiking, diet, and medications. ref SDS 49 8N53 Hiking
470477 - twice or 3 times per week for 1 - 3 miles, at most 9 miles a week,
470478 - correlates to VA assessment that patient "...continues to of hiking
470479 - and follow very active lifestyle," but would not be expected to yield
470480 - improve cardiopulmonary health (e.g., regression of artheriosclerotic
470481 - plaque, effective cholesterol management, blood pressure and heart
470482 - rate that might be derived from hiking 80 miles per week.
470484 - ..
470485 - VA was again notified in a letter on 140211, that patient hiked 933
470486 - miles, dropped weight to 165, and made dietary changes since prior
470487 - review. ref SDS 61 TV40
470489 - ..
470490 - VA Progress Notes HPI 140213 continue...
470491 -
470492 - 3. In our last appointment, we discussed that discussed again that
470493 - despite appropriate diet and exercise, his LDL is still not at
470494 - goal, and increasing exercise activity is of little benefit at
470495 - this point, since elevated cholesterol in his case has a
470496 - genetic component, that needs to be treated with medication.
470498 - ..
470499 - VA Progress Notes saying "...LDL is still not at goal," appears
470500 - conflicting with VA lab on 140203, that shows LDL-C 93, and Labcorp
470501 - blood test on 140201 shows LDL-C 81; VA published "goal" <= 160; and
470502 - Labcorp published "goal" < 100, all shown on 140203 1147. ref SDS 58
470503 - 5C7M Recent guidance published by American Heart Association - AHA -
470504 - shows LDL-C "goal" < 190, reported on 131112 1422. ref SDS 42 HT87
470505 -
470506 - [On 140529 0942 letter asks VA to correct errors in
470507 - Progress Notes for meeting on 140519, so that errors are
470508 - continually carried forward in the record. ref SDS 80 QF6T
470510 - ..
470511 - What is LDL "goal" and published authority supports the representation
470512 - that patient LDL is not at "goal"?
470514 - ..
470515 - VA Progress Notes HPI 140213 continue...
470516 -
470517 - 4. Mr Welch asked about direct measurement of LDL-P vs LDL-C.
470518 - however I don't think that direct measured of LDL-C is of any
470519 - value to his treatment.
470521 - ..
470522 - This repeats error in prior Progress Notes on 131219 0930. ref SDS 50
470523 - NT5J
470525 - ..
470526 - Progress Notes were likely intended to say... "I think direct
470527 - measurement of LDL-P is of no value to his treatment."
470528 -
470529 - [On 140529 0942 letter asks VA to correct errors in
470530 - Progress Notes for meeting on 140519, so that errors are
470531 - continually carried forward in the record. ref SDS 80 QF6T
470533 - ..
470534 - This appears conflicting with VA Progress Notes stating LDL-P has a
470535 - stronger association with cardiovascular risk, reported for meeting on
470536 - 131219 0930. ref SDS 50 GO35 Progress Notes for the meeting today,
470537 - repeat this representation, see below. ref SDS 0 S35H Research on
470538 - discordance between LDL-P and LDL-C concurs with VA that lowering
470539 - LDL-P < 1000 is best indication of low cardiovascular risk, reported
470540 - on 131125 0005, ref SDS 46 FI3G, and was referenced in a letter
470541 - submitted to the VA on 131216 0028. ref SDS 49 6T60 This research was
470542 - cited again in a recent letter to the VA on 140211 0133. ref SDS 61
470543 - TV3M
470545 - ..
470546 - VA Progress Notes HPI 140213 continue...
470547 -
470548 - 5. Recent data shows that The Friedewald equation used to
470549 - calculate LDL tends to UNDERESTIMATE LDL-C levels in the
470550 - setting of high triglyceride levels, especially at low LDL-C
470551 - levels, which could result in undertreatment of high-risk
470552 - patients.
470554 - ..
470555 - What recent data - where is the source?
470557 - ..
470558 - Research shows...
470559 -
470560 - Friedewald formula 470561 - LDL Calculator
470561 -
470562 - http://homepages.slingshot.co.nz/~geoff36/LDL_mg.htm
470564 - ..
470565 - LDL-C = TC - HDL - TG/5
470567 - ..
470568 - VA test on 140203...
470569 -
470570 - = 160 - 58 - 47/5
470571 -
470572 - = 160 - 58 - 9.5
470573 -
470574 - = 92.6
470576 - ..
470577 - Aligns with VA LDL-C 93 in the lab on 140203 1147. ref SDS 58
470578 - 5C7M
470580 - ..
470581 - Labcorp test on 140201...
470582 -
470583 - = 156 - 61 - 68/5
470584 -
470585 - = 156 - 61 - 13.6
470586 -
470587 - = 81.4
470589 - ..
470590 - Aligns with Labcorp LDL-C 81 in the lab on 140201 1159.
470591 - ref SDS 57 5C7M
470593 - ..
470594 - VA Progress Notes HPI 140213 continue...
470595 -
470596 - 6. In mr Welch's case, we already know he is a high risk patient-
470597 - known hx of CAD and both total cholesterol and calculated LDL
470598 - are both well above target.
470600 - ..
470601 - VA lab on 140203 shows TC 160 and goal <= 200; Labcorp lab on 140201
470602 - shows TC 156 and goal < 200. ref SDS 58 5C7M
470604 - ..
470605 - VA lab on 140203 shows LDL-C 93 and goal <= 160; Labcorp lab on 140201
470606 - shows LDL-C 81 and goal < 100. ref SDS 58 5C7M
470608 - ..
470609 - This record indicates Total cholesterol and caclulated LDL are both
470610 - well below target.
470612 - ..
470613 - What supports representation that cholesterol is "above target."
470614 - What are the targets? What is the authority?
470616 - ..
470617 - VA Progress Notes HPI 140213 continue...
470618 -
470619 - 7. Regarding LDL-P, after discussing the case with Dr
470620 - Feindgold- LDL-P is usually measured to assess risk for
470621 - cardiovascular disease, in patients with OPTIMAL levels of
470622 - LDL. For these patients, measuring and lowering LDL-P is
470623 - considered a primary goal of therapy due to its stronger
470624 - association with cardiovascular risk. In Mr Welch's case,
470625 - his LDL-C is not at optimal levels, so again measuring of
470626 - LDL-P will add no benefit to treatment management. He ahd
470627 - repeat lipid panel at the Va, and at Labcorp- labs at
470628 - Labcorp included LDL-P of 861.
470630 - ..
470631 - This aligns with discussion during the meeting today and prior
470632 - correspondence, per above, ref SDS 0 UV4O, and largely repeats
470633 - representation in Progress Notes for meeting at the VA on 131219 0930.
470634 - ref SDS 50 GO35
470635 -
470636 - [...below on 140213 0830 VA Progress Notes reference
470637 - discussion with Doctor Feingold, who presented the same
470638 - analysis shown in Progress Notes for the meeting on 131219.
470639 - ref SDS 0 K49F
470641 - ..
470642 - [On 140519 0800 meeting at the VA Doctor Alba pleased LDL-P
470643 - 851 declined, further below published guidance that signals
470644 - very healthy cholesterol levels, that lowers CVD risk.
470645 - ref SDS 77 X59G Reviewed research again showing low LDL-P
470646 - and high LDL-C present lowest risk of CVD. ref SDS 77 T97N
470648 - ..
470649 - The statement that LDL-C is not at optimal levels requires
470650 - clarification of "optimal level," based on analysis showing the labs
470651 - on 140201 and 140203 show LDL-C below VA targets, per above.
470652 - ref SDS 0 5I7H
470654 - ..
470655 - Need to clarify LDL-P 861 cited in this section of Progress Notes,
470656 - based on Labcorp blood test on 140201 1159. ref SDS 59 BE6O Since
470657 - LDL-P has stronger association with cardiovscular risk, what is the
470658 - "goal" and "optimal level" for LDL-P?
470660 - ..
470661 - VA Progress Notes HPI 140213 continue...
470662 -
470663 - 8. Today, he denies CP, SOB, abdominal pain, muscl pain.
470665 - ..
470666 - 3. Pertinent history.
470667 -
470668 - 1. Patient was started on Simvastatin approximately 2-3 years
470669 - ago, LDL at that time was around 180's - reports that his
470670 - LDL dropped to 96 while on simvastatin, however he reports
470671 - he develop "left shoulder myopathy"- he described pain on
470672 - his left shoulder and inability to raise it above 90
470673 - degrees- No CPK on records.
470675 - ..
470676 - 2. He was then started on Rosuvastatin 10 mg po daily
470677 - and report that his LDL improved. Rosuvastatin was then
470678 - increased to 20 mg and he developed sexual dysfunction,
470679 - dizziness, dry mouth and right foot numbness.
470681 - ..
470682 - Major side effect is frequent urination causing dehydration. One
470683 - manifestation of dehydration is "dry mouth." There was some left foot
470684 - numbness as well, but mostly noticed in right foot.
470686 - ..
470687 - Progress Notes Pertinent history 140213 continue...
470688 -
470689 - 3. As per cardiology notes in September 2012- rosuvastatin was
470690 - decreased to 10mg po daily and dizziness improved, but he
470691 - continued to complain of right foot numbness. He now has
470692 - he has been off the rosuvastatin since 12/2012, and he
470693 - continues to complain of right foot numbness, but he
470694 - reports less episodes of right sole numbness with decreased
470695 - intensity.
470697 - ..
470698 - See comment on Progress Notes for meeting on 131121, presenting record
470699 - on peripheral neuropathy, also called numbness. ref SDS 44 E34O
470701 - ..
470702 - Progress Notes Pertinent history 140213 continue...
470703 -
470704 - 4. Of note, he was seen by neurology February 2013 for the
470705 - foot numbness, Vit B12 level was within normal range,
470706 - fasting glucose level ranges from 108 to 115 mg/dl, Hga1c
470707 - 5.5 October 2013; as per neurology notes no evidence of
470708 - radiculopathy or neuropathy.
470710 - ..
470711 - See comment on Progress Notes for meeting on 131121, presenting record
470712 - on HGA1c lab results. ref SDS 44 XQ7R
470714 - ..
470715 - VA Progress Notes PMH 140213 continue...
470716 -
470717 - 4. PMH:
470718 -
470719 - 1. Esophageal Achalasia
470720 - 2. CAD s/p CABG x4 in 2009
470721 - 3. GERD
470722 - 4. Hyperlipidemia
470724 - ..
470725 - 5. Surgical, social and family history reviewed an unchanged
470727 - ..
470728 - This notes reflects entry in Progress Notes para 4, PSH, for meeting
470729 - at VA on 131121 0930. ref SDS 44 W49F
470731 - ..
470732 - Corrections to family history reported in VA Progress Notes on 131121
470733 - 0930, ref SDS 44 U45N, were submitted to the VA on 131216 0028.
470734 - ref SDS 49 8N61
470736 - ..
470737 - VA Progress Notes Medications 140213 continue...
470738 -
470739 - 6. MEDICATIONS
470740 -
470741 - 1. Omeprazole 20 mg BID
470742 - 2. Atorvastatin 10 mg po daily
470743 - 3. Zetia 10 mg po daily
470745 - ..
470746 - 7. PHYSICAL EXAM
470747 -
470748 - 1. Vital Signs:
470749 -
470750 - 1. HT: 66 in [167.6 cm] (12/16/2009 18:00)
470751 - 2. WT: 178 lb [80.9 kg] (02/13/2014 08:19)
470752 - 3. HR: 67 (02/13/2014 08:19)
470753 - 4. BP: 108/67 (02/13/2014 08:19)
470754 - 5. Temp: 97.1 F [36.2 C] (12/20/2009 08:46)
470755 - 6. RR: 18 (02/13/2014 08:19)
470756 - 7. O2 Sat: 2/13/14 08:19:09 O299 BMI: 28.8 (Overweight)
470757 - 8. PE deferred
470759 - ..
470760 - 8. LABS:
470762 - ..
470763 - VA Progress Notes Labs 140213 continue...
470764 -
470765 - 1. VA February 3, 2014.......... ref SDS 58 5C7M
470766 -
470767 - TC............. 160
470768 - LDL............ 93
470769 - HDL............ 58
470770 - TG............. 47
470771 - HGA1c.......... 5.5
470773 - ..
470774 - 2. Labcorp February 1, 2014.......... ref SDS 57 5C7M
470775 -
470776 - TC............. 156
470777 - LDL............ 81
470778 - HDL............ 61
470779 - TG............. 61
470780 -
470781 - F:\05\00441\SM\BGMC\20140203-095241\Welch 02042014.pdf
470783 - ..
470784 - Labcorp performed NMR lipid profile on 140201 1159, ref SDS 57 BE6O,
470785 - and shows TG 68, not 61, as reported by VA Progress Notes. ref SDS 57
470786 - 5C7M
470787 -
470788 - [On 140529 0942 letter asks VA to correct errors in
470789 - Progress Notes for meeting on 140519, so that errors are
470790 - continually carried forward in the record. ref SDS 80 QF6T
470792 - ..
470793 - VA Progress Notes Labs 140213 continue...
470794 -
470795 - 3. October 15, 2013..................... ref SDS 38 BE6O
470796 -
470797 - TC............. 321
470798 - LDL............ 249
470799 - HLD............ 50
470800 - TG............. 85
470801 - TBil........... 1.7
470802 - HGA1c.......... 5.5
470803 - CPK............ 110
470804 - TSH............ 2.6
470806 - ..
470807 - F:\05\00441\SM\BGMC\20131015-082536\Welch 10-18-13.pdf
470809 - ..
470810 - HLD 50 should be HDL 50 - minor correction. Repeats error in prior
470811 - Progress Notes on 131219 0930, ref SDS 50 FJ6G, and previously on
470812 - 131121 0930. ref SDS 44 FJ6G
470814 - ..
470815 - Triglycerides (TG) 109 not 85, for VA lab on 131015 0724. ref SDS 38
470816 - BE6O Repeats error in notes for prior meetings on 131121 0930,
470817 - ref SDS 44 FJ6G, and for 131219. ref SDS 50 FJ6G
470818 -
470819 - [On 140529 0942 letter asks VA to correct errors in
470820 - Progress Notes for meeting on 140519, so that errors are
470821 - continually carried forward in the record. ref SDS 80 QF6T
470823 - ..
470824 - CPK 110 and Tsh 2.6 are not evident in VA report for lab on 140203
470825 - 1147. ref SDS 58 NX6G
470827 - ..
470828 - CPK 110 shown in Progress Notes today, may be CK 110 in VA lab on
470829 - 131015 0724. ref SDS 38 D26G Seems to repeat prior error showing CPK
470830 - and TSH in Progress Notes for prior meeting on 131219 0930.
470831 - ref SDS 50 FJ6G
470833 - ..
470834 - VA Progress Notes LABS meeting 131219 continues...
470835 -
470836 - 4. May 2013................ 130529 0818, ref SDS 32 BE6O
470837 -
470838 - TC............. 307
470839 - LDL............ 240
470840 - HLD............ 54
470841 - TG............. 85
470842 - TBil........... 1.3
470843 -
470844 - F:\05\00441\SM\BGMC\20130529-081837\welch 6-14-2013.pdf
470846 - ..
470847 - HLD 54 should be HDL 50. Repeats error in prior Progress Notes on
470848 - 131219 0930, ref SDS 50 FJ7H, and previously on 131121 0930.
470849 - ref SDS 44 FJ7H
470850 -
470851 - [On 140529 0942 letter asks VA to correct errors in
470852 - Progress Notes for meeting on 140519, so that errors are
470853 - continually carried forward in the record. ref SDS 80 QF6T
470855 - ..
470856 - VA Progress Notes LABS meeting 131219 continues...
470857 -
470858 - 5. November 2012
470859 -
470860 - TC............. 173
470861 - LDL............ 105
470862 - HLD............ 57
470863 - TG............. 53
470864 - TBil........... 1.6
470865 -
470866 - F:\05\00441\SM\BGMC\20121130-100104\welch 121412.pdf
470868 - ..
470869 - 6. December 14, 2009
470870 -
470871 - TC............. 241 H 100 - 240 PLASMA
470872 - LDL (Calcultd). 170 H - 131 PLASMA
470873 - HLD............ 44 35 - PLASMA
470874 - TG............. 136 10 - 190 PLASMA
470875 -
470876 - F:\05\00441\SM\BGMC\20091022-175119\welch0144.pdf
470878 - ..
470879 - 9. Assessment and Plan:
470880 -
470881 - 1. 68 year old male with history of CAD, s/p CABG in 2009,
470882 - Hyperlipidemia, referred by cardiology for management of
470883 - hyperlipidemia. Here today for follow up.
470884 -
470885 - 2. Improved LDL on atorvastatin 10 mg po daily and Zetia 10 mg
470886 - daily. LDL of 93 down from 249 in October 2014.
470888 - ..
470889 - Progress Notes should further note LDL-C 81 reported in Labcorp lab on
470890 - 140201, 2 days before VA reported LDL-C 93, shown in the record on
470891 - 140203 1147. ref SDS 58 5C7M
470893 - ..
470894 - Progress Notes should further report that, since prior lab on 131015,
470895 - until lab at VA today on 140203, case study on 120101, ref SDS 13
470896 - E47L, shows patient has taken...
470897 -
470898 - 1. Atorvastatin............... 1850 mg
470899 - 2. Ezetimibe.................. 340 mg
470901 - ..
470902 - Progress Notes should also report improved HDL 61 (Labcorp) and 58
470903 - (VA), and Improved TG 68 (Labcorp) and 47 (VA), which together yield
470904 - favorable LDL-P 861, are significantly better than VA "targets" and
470905 - published guidelines for CVD "goals," shown in the record on 140203
470906 - 1147. ref SDS 58 BE6O Correlation between TG, HDL and LDL-P is shown
470907 - in the record on 131125 citing article by Doctor Sigurdsson reviewing
470908 - relevant studies. ref SDS 46 1D8H
470910 - ..
470911 - Diet, exercise and weight loss should be reported in Progress Notes
470912 - concurrent with improved lipid lab profile, as shown in the record on
470913 - 140203 1147. ref SDS 58 I17G
470915 - ..
470916 - VA Progress Notes Assessment and Plan meeting 131219 continues...
470917 -
470918 - 3. Patient had nonspecific flu-like symptoms that have
470919 - resolved.
470921 - ..
470922 - Cold/flu symptoms are side effects caused by Atorvastatin listed on
470923 - 130603 0930. ref SDS 36 PC6O
470925 - ..
470926 - Cold/flu symptoms are side effects caused by Ezetimibe listed on
470927 - 131125 0005. ref SDS 46 GD8G
470929 - ..
470930 - VA Progress Notes Assessment and Plan meeting 131219 continues...
470931 -
470932 - 4. I reviewed with Mr Welch his website, where he cites
470933 - information from Dr Attia regarding discordant Lipids,
470934 - however data is incomplete and we could not find the
470935 - relevant literature [unable to access articles, only
470936 - diagrams are available].
470938 - ..
470939 - Progress Notes are incomplete failing to present what "diagrams" show,
470940 - that is relevant to patient lipid profile, and whether the diagrams in
470941 - the Attia article conflict with other diagrams VA relies upon to
470942 - assess patient status and guide prescriptions for treatment.
470949 - ..
470950 - Progress Notes should present patient record on 131125, ref SDS 46
470951 - FI3G, showing information citing Doctor Attia's article, and what
470952 - specifically is shown relevant to goals for controlling
470953 - atherosclerosis by managing lipid panel profile for discordance
470954 - between LDL-P and LDL-C...
470955 -
470956 - The highest risk and lowest risk groups are those with
470957 - discordant LDL-C and LDL-P. The high risk group has
470958 - high LDL-P and low LDL-C, while the lowest risk group
470959 - has high LDL-C with low LDL-P. Only a minority of
470960 - physicians would know that there is a segment of the
470961 - population with elevated LDL-C who are at low risk!
470962 - The same conclusion will be drawn from the next study.
470964 - ..
470965 - This was discussed during the meeting this morning, per above,
470966 - ref SDS 0 UV4O, citing correspondence previously submitted to the VA
470967 - on....
470968 -
470969 - 1. 140114. ref SDS 52 2140
470970 - 2. 140116. ref SDS 54 H29T
470971 - 3. 140211. ref SDS 61 TV3M
470973 - ..
470974 - [On 140519 0800 meeting at the VA Doctor Alba pleased LDL-P
470975 - 851 declined, further below published guidance that signals
470976 - very healthy cholesterol levels, that lowers CVD risk.
470977 - ref SDS 77 X59G Reviewed research again showing low LDL-P
470978 - and high LDL-C present lowest risk of CVD. ref SDS 77 T97N
470980 - ..
470981 - VA Progress Notes Assessment and Plan meeting 131219 continues...
470982 -
470983 - 5. Dr Feingold had an extensive discussion with Mr welch regarding
470984 - LDL-P and discordant LDL-c and LDL-P, which follows the same
470985 - principles of our previous conversations- please note form
470986 - December 19 2013.
470988 - ..
470989 - VA Progress Notes on 131219, say in part...
470990 -
470991 - Regarding LDL-P, after discussing the case with Doctor
470992 - Feingold - LDL-P is usually measured to assess risk for
470993 - cardiovascular disease, in patients with OPTIMAL levels
470994 - of LDL. For these patients, measuring and lowering
470995 - LDL-P is considered a primary goal of therapy due to
470996 - its stronger association with cardiovascular risk. In
470997 - Mr Welch's case, his LDL-C is not at optimal levels, so
470998 - again measuring of LDL-P will add no benefit to
470999 - treatment management. ref SDS 50 GO35
471001 - ..
471002 - VA Progress Notes for today on 140213, citing prior Progress Notes on
471003 - 131219, also align with these same Progress Notes for today, shown
471004 - above, that LDL-P has stronger association with CVD risk than LDL-C.
471005 - ref SDS 0 S35H
471007 - ..
471008 - Progress Notes can be strengthened by stating what LDL-C levels are
471009 - "optimal" in relation to lipid labs performed on 140203 1147.
471010 - ref SDS 58 BE6O
471012 - ..
471013 - Patient records show Doctor Feingold indicated today that LDL-P can be
471014 - "assumed" from triglyceride/HDL ratio, and therefore it is unnecessary
471015 - to directly measure LDL-P, per above. ref SDS 0 WQ8L
471017 - ..
471018 - Progress Notes can be strengthened by stating what LDL-P level can be
471019 - assumed from TG/HDL ratios in labs reported on 140203 1147.
471020 - ref SDS 58 BE6O Is LDL-P 626 correctly assumed from VA lab on 140203,
471021 - as calculated in the record? 140203 1147? ref SDS 58 4Z66
471023 - ..
471024 - Patient records further indicate Doctor Feingold cautioned against
471025 - reliance on discordance with low LDL-P < 700 and high LDL-C > 160, for
471026 - large "pattern A" LDL particles to protect against advance of CVD,
471027 - which is cited in research presented by Doctor Attia and others shown
471028 - on 131125 0005. ref SDS 46 OQ9N The doctor seemed indicate that
471029 - discordance is very rare - see above. ref SDS 0 EO9O
471031 - ..
471032 - Patient records further indicate Doctor Feingold explained today, that
471033 - the difference between LDL particle size A and size B is "small."
471034 - Therefore, even though patient's NMR lab test on 140201 shows LDL
471035 - particle size fits criteria for "healthy" - i.e., "large" pattern A,
471036 - 140201 1159, ref SDS 57 5C86, rather than protect against penetration
471037 - of the endothelial lining, high LDL-C > 160 represents elevated risk
471038 - for CVD - see again above. ref SDS 0 S48M
471040 - ..
471041 - VA Progress Notes Assessment and Plan meeting 131219 continues...
471042 -
471043 - 6. Plan
471044 -
471045 - 1. Continue Atorvastatin 10 mg po daily and Zetia 10 mg po
471046 - daily.
471048 - ..
471049 - 2. Weight stable, continue physical activity and low
471050 - fat/low cholesterol diet.
471052 - ..
471053 - This aligns with discussion during the meeting, reported above.
471054 - ref SDS 0 IU4H
471056 - ..
471057 - Progress Notes align with the record of physical activity hiking 11
471058 - miles per day and 933 miles over past 4 month test cycle, along with
471059 - diet regimen yielding improved labs and weight loss reported in the
471060 - letter to VA on 140211 0133, ref SDS 61 TV40, and citing review of
471061 - favorable labs in the record on 140203 1147. ref SDS 58 I17G
471062 -
471063 - [On 140519 0800 follow up lab shows HDL 65 increased
471064 - from HDL 61, reflects implementation and success of
471065 - Doctor Alba's prescription to continue extended
471066 - endurance exercise. ref SDS 77 MY7J
471068 - ..
471069 - [On 140629 1921 follow up letter to VA on 140520,
471070 - ordering coronary CTA with calcium score, ref SDS 79
471071 - VQ48, to assess reducing level of care hiking 11
471072 - miles per day in order to reduce side effects,
471073 - ref SDS 81 UZ64; further request referral to Podiatry
471074 - for consultation to relieve metatarsalgia side
471075 - effects of prescribed care. ref SDS 81 U14H
471077 - ..
471078 - VA Progress Notes Assessment and Plan meeting 131219 continues...
471079 -
471080 - 3. RTC in 3 months. Plan to repeat lipid panel before
471081 - next appointment
471082 -
471083 -
471084 - 10. Clinical Reminder Activity
471085 -
471086 - MED REC NON PRIMARY CARE:
471088 - ..
471089 - Medication Reconciliation completed, including non-VA
471090 - medications and discrepancies, if identified, were addressed.
471091 - Medication, medication changes and importance of medication
471092 - management were reviewed with the patient/caregiver. An
471093 - updated list of reconciled medications has been provided to the
471094 - patient/caregiver.
471096 - ..
471100 -
471101 - [On 140312 1720 submitted comments on Progress Notes,
471102 - requesting document identification data, and submitting
471103 - comments. ref SDS 71 5N3O
471104 -
471105 -
471106 -
471107 -
471108 -
471109 -
471110 -
471111 -
471112 -
471113 -
471114 -
471115 -
471116 -
4712 -