CONTACTS
SUBJECTS
VA Pharmacy Ezetimibe Order Refill Treat Cholesterol LDL 249 Prescri
5703 -
5703 - ..
5704 - Summary/Objective
5705 -
570501 - Follow up ref SDS A4 0000. ref SDS A3 0000.
570502 -
570503 -
570504 -
570505 -
570507 - ..
5706 -
5707 -
5708 - Background
5709 -
570901 - EGD on 101210, seems to show progress recovering from esophagitis; the
570902 - doctor dilated the LESV from 11 to 14 cm, reported on 101210 0930,
570903 - ref SDS 49 XG6J
570905 - ..
570906 - Follow up EGD planned for February, ref SDS 49 L94L.
570908 - ..
570909 - Doctor Lee prescribed doubling dose of Omeprazole to increse recover
570910 - from esophagitis, reported on 101210 0930. ref SDS 49 ZN4M
570912 - ..
570913 - On 101216 appears Doctor Lee ordered refill for omeprazole. ref SDS 51
570914 - 8785
570916 - ..
570917 - On 110320 0750 ordered refill Omeprazole to treat Achalasia,
570918 - ref SDS 58 5N3O,
570920 - ..
570921 - On 110626 0721 ordered refill Omeprazole to treat Achalasia.
570922 - ref SDS 62 5N3O
570924 - ..
570925 - On 110913 2238 ordered refill Omeprazole to treat Achalasia,
570926 - ref SDS 63 5N3O
570928 - ..
570929 - On 120326 1549 ordered refill Omeprazole to treat Achalasia,
570930 - ref SDS 70 5N3O
570932 - ..
570933 - On 120330 1439 received refill Omeprazole to treat Achalasia.
570934 - ref SDS 71 5N3O
570936 - ..
570937 - On 120906 1100 Doctor Egan reduced dose Omeprazole 20 mg from 40 mg,
570938 - which increased effective treatments with current prescription.
570939 - ref SDS 74 W165
570941 - ..
570942 - On 120925 1300 Doctor Lee increased dose Omeprazole 40 mg from 20 mg,
570943 - which decreases effective treatments under current prescription.
570944 - ref SDS 75 K37G
570946 - ..
570947 - On 120927 1214 could not order refill prescription for Omeprazole.
570948 - ref SDS 76 3Z4M
570950 - ..
570951 - On 121001 0820 VA ordered new prescription Omeprazole with 3 remaining
570952 - refills, ref SDS 78 5N3O, VA also ordered Fluconazole 200 mg, which is
570953 - not explained in the record, ref SDS 78 EO5H, and further which
570954 - increases side effects for Rosuvastatin, ref SDS 78 0450, but on plus
570955 - side Fluconazole resolves electrolytes abnormalites, in this case
570956 - Total Bilirubin is nearly 100% over healthy range, causing peripheral
570957 - neuropathy. ref SDS 78 ZH6J
570959 - ..
570960 - On 121003 1438 received in the mail Omeprazole with incorrect dose
570961 - prescription. ref SDS 79 5N3O
570963 - ..
570964 - On 121003 1438 received in the mail RX # 10864663B which conflicts
570965 - with RX #10864663A, ref SDS 78 5N3O and dose instructions to take 2
570966 - pills twice a day, ref SDS 78 MH65, conflict with the doctor's order
570967 - to take 1 pill twice per day.
570969 - ..
570970 - On 130416 1100 Doctor Lee reported the VA placed hold that prevented
570971 - patient from ordering any of 3 refills of Omeprazole; the doctor
570972 - cancelled the prior order and placed new order for current
570973 - prescription with 3 refills of Omeprazole. ref SDS 82 RG9K
570975 - ..
570976 - On 130423 1140 received refill for Omeprazole. ref SDS 84 5N3O
570978 - ..
570979 - On 131115 0800 meeting Doctor Lee EGD Dilation, continued prescription
570980 - for Omeprazole to aid digestion. ref SDS 87 R74M
570982 - ..
570983 - On 131121 1604 ordered refill for Omeprazole. ref SDS 89 AG9I
570985 - ..
570986 - On 131205 1448 received prescription for Atorvastatin 20 MG,
570987 - ref SDS 92 5N3O, ordered by Doctor Alba during the meeting at the VA
570988 - on 131121 0930. ref SDS 88 6H6K
570990 - ..
570991 - On 131219 0930 Doctor Alba ordered Ezetimibe 10 mg to take with
570992 - Atorvastatin 10 mg, during meeting at VA. ref SDS 93 6H6K
570994 - ..
570995 - On 131230 1450 received Ezetimibe from VA to combine with
570996 - Atorvastatin. ref SDS 94 5N3O
570998 - ..
570999 - On 140127 1821 ordered refill Ezetimibe from VA. ref SDS 95 5N3O
571001 - ..
571002 - On 140201 1353 received refill Ezetimibe from VA.
571004 - ..
571005 - On 140226 2035 only have 4 pills for Atorvastatin and Ezetimibe, so
571006 - ordered refills. ref SDS 99 4P5M
571007 -
571008 -
571009 -
571010 -
571012 - ..
5711 -
5712 -
5713 - Progress
5714 -
571401 - Progress Notes Meeting 140213 Transmitted VA System Email
571402 - VA System Email Transmitted Progress Notes Meeting 140213
571403 -
571404 - Follow up ref SDS A4 5N3O, ref SDS A3 5N3O.
571405 -
571406 - Sent letter to VA saying...
571407 -
571408 - 1. Subject: Prog Notes 13 Feb 2014 Comments
571409 - Date: 2014-03-12 18:13
571416 - ..
571417 - 2. Subject Progress Notes preliminarily are missing the header;
571418 - assume it is something like...
571420 - ..
571421 - LOCAL TITLE: ENDOCRINE-METABOLISM CLINIC (MED)
571422 - STANDARD TITLE: ENDOCRINOLOGY OUTPATITNE NOTE
571423 - DATE OF NOTE: FEB 13, 2014 @ 0830
571424 - ENTRY DATE: MAR __ 2014 @______
571425 - AUTHOR: ALBA, DIANA
571426 - EXP COSIGNER:
571427 - URGENCY:
571428 - STATUS: COMPLETED
571430 - ..
571431 - 3. At the bottom...
571432 -
571433 - Signed: __/__/2014 ____
571435 - ..
571436 - 4. Can you please submit this?
571438 - ..
571439 - 5. Have tried getting it through ROI channels. Martinez has had
571440 - numerous personnel changes. The most recent attendant, Jeff,
571441 - said today that Bless faxed a request to ROI at San Francisco
571442 - VA Med Center last week, would not say when. He called
571443 - Kathleen, who has transferred to Sacramento, for assistance.
571444 - She had the job for a year on a temporary basis, and was
571445 - terrific, emailing Progress Notes. For some reason, she could
571446 - not help Jeff today, her former boss, go through the mechanics
571447 - of accessing the record in San Francisco, doing a copy and
571448 - attaching to an email.
571450 - ..
571451 - 6. There is no rush on this - whenever you have a moment to
571452 - complete the record is fine.
571454 - ..
571455 - 7. Heads up - not criticism, because I like working with you, and
571456 - respect your medical practice. That said there are many
571457 - grammatical errors in the notes, which you might consider
571458 - correcting for the next issue in May. If you need a list, just
571459 - me let know. I realize this may not be a good use of your
571460 - time.
571462 - ..
571463 - Implements planning to submit comments on Progress Notes for meeting
571464 - on 140213, as set out in the letter to the VA on 140310 0939.
571465 - ref SDS A4 M33I
571467 - ..
571468 - Letter to VA continrues...
571469 -
571470 - 8. Additionally, the notes show a sentence that says in part...
571471 -
571472 - "...however I don't think that direct measured of LDL-C is of
571473 - any value to his treatment." [see the record on 140213 0830.
571474 - ref SDS 97 E66J...].
571476 - ..
571477 - 9. You may have intended to say "LDL-P" rather than LDL-C, since
571478 - the gravamen of the notes taken by the 4-corners rests entirely
571479 - on lowering LDL-C to "goal," though without stating the goal.
571481 - ..
571482 - 10. For some reason no other lipid "goals" are mentioned in the
571483 - Progress Notes.
571485 - ..
571486 - 11. Recall during the meeting, Doctor Feingold seemed to indicate
571487 - that measuring LDL-P is unnecessary because it can be assumed
571488 - from triglyceride (TG)/HDL ratio. The notes say nothing about
571489 - a 20% rise in HDL 61-Labcorp, nor a 60% drop in TG 47-VA, nor
571490 - what LDL-P level can be drawn from these valuations.
571492 - ..
571493 - 12. The notes further say in part...
571494 -
571495 - "For these patients, measuring and lowering LDL-P is considered
571496 - a primary goal...due to its stronger association with
571497 - cardiovascular risk." [...reported on 140213 0830. ref SDS 97
571498 - S35H...].
571500 - ..
571501 - 13. VA's focus on LDL-C is appreciated, and setting aside
571502 - consideration of discordance [...see history considering
571503 - "discordance" in relation to VA Progress Notes in the record on
571504 - 140213 0830. ref SDS 97 I35L...], what are the goals for HDL
571505 - and TG to lower LDL-P that has the strongest association with
571506 - CVD risk?
571508 - ..
571509 - 14. As well, some mention might be helpful in the Notes of diet,
571510 - along with exercise increase to nearly 1000 miles in 3 months
571511 - to complement medication for dramatic rise in HDL 21% and
571512 - reduction of TG 60%, given that research indicates Atorvastatin
571513 - and Ezetimibe have been found to increase HDL 5%-9%, and lower
571514 - TG 30%-40% [...reported on 131125 0005. ref SDS 90 PU6I...] -
571515 - see AHA article Circulation published 030428...
571516 -
571517 - https://circ.ahajournals.org/content/107/19/2409.full
571519 - ..
571520 - 15. LDL-C lowered 63% on VA lab, and 75% on Labcorp. The same AHA
571521 - source indicates LDL-C lowered 50%-60% with Atorvastatin
571522 - Ezetimibe, suggesting some other factor may be at play.
571524 - ..
571525 - 16. As well there is nothing mentioned in the notes on evaluating
571526 - regression of atherosclerosis systemic plaque. Since elevated
571527 - HDL in combination with low TG drive regression, should some
571528 - mention be cited in the Notes on this opportunity for lowering
571529 - CVD risk? [...discussed during the meeting on 140213 0830,
571530 - ref SDS 97 JZ4O, citing research on 131125 0005. ref SDS 90
571531 - E13K...].
571532 -
571533 - [On 140519 0800 follow up meeting with Doctor Alba;
571534 - attending physician Doctor Feingold advised that complex
571535 - anatomy of blood vessels intertwined by CABG surgery
571536 - prevents radiology analysts from reading CCTA scan tests
571537 - to evaluate regression of atherosclerosis. ref SDS A5
571538 - J83H
571540 - ..
571541 - 17. Finally, the Notes say in part...
571542 -
571543 - "Mr Welch states that he would like to stop medication and then
571544 - recheck lipids in a couple of months, to see what would
571545 - happened to LDL-C and LDL-P."
571547 - ..
571548 - 18. Sometimes we say things in the heat of meetings, which are not
571549 - intended, but somehow get said anyway. This happens as well in
571550 - written correspondence and reports, e.g., inadvertantly
571551 - substituting LDL-C for LDL-P, see above. ref SDS 0 IL87 If
571552 - that happened in this case, I apologize. My intent is to
571553 - continue current regimen, and test in 3 months to see if good
571554 - results on 140201 and 140203 can be maintained, since
571555 - previously initial good results with Simvastatin and
571556 - Rosuvastatin did not continue during 2011 and 2012. Down the
571557 - road, if good results continue in 6/9/12 months or so, then we
571558 - might consider dropping meds, if CT testing shows plaque has
571559 - dramatically regressed - its an option.
571561 - ..
571562 - 19. Again, you have done great work in this case. Don't worry
571563 - about changing the Notes, if its more trouble than its worth.
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