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


S U M M A R Y


DIARY: February 13, 2014 08:30 AM Thursday; Rod Welch

VA meeting Atorvastatin and Ezetimibe manage cholesterol Doctor Alba SF Medical Center.

1...Summary/Objective
2...Hyperlipidemia Cholesterol Controlled Exercise Diet Medication
3...Cholesterol Managed Clinical Trial Exercise Diet Medication
4...VA Excellent Health Care Aligns Lipid Panel with Good Health Ranges
............Why is it necessary to measure LDL-P, instead of just LDL-C?
5...Medical Chart Progress Notes Meeting 140213 VA SF Medical Center
........Friedewald formula 470561 - LDL Calculator


..............
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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 -