CONTACTS 

SUBJECTS
VA Prescribe Atorvastatin 10 MG Trial 4 Weeks Evaluate Side Effects In   48                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
6003 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
6003 -    ..
6004 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
6005 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
600501 - Follow up ref SDS 81 0000. ref SDS 70 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
600502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
600503 - Productive meeting with VA team; Doctor Alba ordered additional lab to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600504 - check Chem Profile on elevated potassium that may cause electrical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
600505 - problems for the heart, noted by Doctor Egan in Cardiology at VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600506 - Clinic in Martinez.  Potassium and other electrolytes were reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
600507 - high in Labcorp test, but are needed in VA system for efficient case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
600508 - management. ref SDS 0 HY6O  VA has done excellent work with plan of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
600509 - care combining medication and physical activity to maintain favorable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
600510 - lipid labs. ref SDS 0 X59G  Physical activity with endurance exercise                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
600511 - hiking 300+ miles per month increased HDL 67 from 30, when CABG +4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
600512 - surgery was performed 5 years ago in 2009.  Equally, EPCs are likely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
600513 - elevated, which causes regression of atherosclerosis, and which in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
600514 - turn lowers CVD risk. ref SDS 0 T64J  Orange juice was also increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
600515 - in line with studies showing positive effects increasing HDL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
600516 - ref SDS 0 4Z8I  Coronary CTA with calcium score provides standard of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
600517 - care testing response to treatment reducing atherosclerosis plaques to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600518 - evaluate level of care managing CVD risk. ref SDS 0 WS4L  The medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
600519 - team worries patient anatomy changes from CABG surgery in 2009, makes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
600520 - testing difficult with coronary CTA. ref SDS 0 J83H  Research                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
600521 - indicates CTA radiology modalities are standard of care for testing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
600522 - response to treatment after CABG surgery. ref SDS 0 OF7N  Patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
600523 - history of elevated atherosclerosis was cited during the meeting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
600524 - There was concern testing severity of atherosclerosis after 5 years of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600525 - treatment will not add value to adjust treatment regardless of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
600526 - results. ref SDS 0 M16K  Reviewed standard of care for evidenced based                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600527 - medical practice requires testing to measure severity of medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600528 - problems that guides treatment.  Coronary CTA with calcium score                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600529 - yields results in time to make effective changes, ref SDS 0 6W3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600530 - Patients need timely testing to avoid tragic outcomes illustrated by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
600531 - Tim Russert case, where results came too late for survival.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
600532 - ref SDS 0 NB7N  Doctor Alba noted favorable labs indicate current                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
600533 - treatment is effective, so why test for regression of atherosclerosis?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600534 - ref SDS 0 467K  Reviewed rising side effects of prescribed care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600535 - ref SDS 0 PC8K  The doctor referred urination side effects to Primary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
600536 - Care for possible prostate issues arising from aging process.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
600537 - ref SDS 0 EK4F  Doctor Alba will add T Bili to make-up electrolytes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
600538 - lab in order to evaluate rising peripheral neuropathy. ref SDS 0 P26G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
600539 - The doctor will investigate referral to podiatry for relief of side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
600540 - effects hiking 300 miles per month in order to maintain level of care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
600541 - required for regression of atherosclerosis. ref SDS 0 YM5N  Considered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600542 - reducing treatment to lower side effects.  Since current care has been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600543 - effective there is reluctance to reduce treatment without evidence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
600544 - atherosclerosis plaques have regressed that lower CVD risk.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600545 - doctor advised that minor side effects must be tolerated in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
600546 - benefit from lowering risks of atherosclerosis.  Doctor Alba will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
600547 - discuss with the VA team using coronary CTA with calcium score to test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600548 - for regression of atherosclerosis that will provide evidence that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
600549 - supports reducing debilitating side effects by reducing treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
600550 - ref SDS 0 635O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
600552 -             ..
600553 -            [On 140520 0732 letter to VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
600554 -            Francisco cites discussion on sore feet side effects of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
600555 -            hiking to lower CVD risk. ref SDS 97 UT5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
600557 -             ..
600558 -            [On 140520 0732 at 1017 VA lab Chem Profile shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600559 -            electrolytes generally improved - potassium (K) 5.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
600560 -            declined from 5.6 on Labcorp test on 140508, and from 5.4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
600561 -            in VA lab on 140203 - additionally, glucose 98 declined                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
600562 -            from 103, sodium 139 declined from 144, and T Bil 1.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600563 -            declined from 2.2. ref SDS 97 ZG5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
600565 -             ..
600566 -            [On 140529 0942 letter to VA requests progress ordering EPC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
600567 -            lab, and requests order for coronary CTA with calcium score                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600568 -            standard of care testing response to treatment for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
600569 -            regression of atherosclerosis. ref SDS A1 QG38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
600571 -             ..
600572 -            [On 140612 1048 letter from Doctor Alba says VA refuses to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
600573 -            order EPC and CTA tests to evaluate regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
600574 -            atherosclerosis because CABG surgery on 091022, changed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
600575 -            anatomy which renders CTA test difficult, and since                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
600576 -            customer has history of atherosclerosis the VA will not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
600577 -            test whether the problem has been resolved, declined,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600578 -            unchanged or worsened, ref SDS A2 X45G, reflecting remarks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
600579 -            by Doctor Feingold as presented in Progress Notes for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600580 -            meeting at VA on 140519 0800. ref SDS 0 OW49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
600582 -             ..
600583 -            [On 140626 1652 letter notifies VA case studies show                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
600584 -            failure to perform timely testing causes negative patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
600585 -            outcomes. ref SDS A4 MY51  VA reference to patient having                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
600586 -            vessel plaques 5 years ago, begs the question of testing to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600587 -            determine how much plaque, and level of care required, if                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
600588 -            any, to treat current condition. ref SDS A4 MZ33  Evidence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
600589 -            shows CTA common practice to evaluate atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600590 -            post CABG surgery. ref SDS A4 MZ54                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
600592 -             ..
600593 -            [On 140929 1418 received letter from Doctor Alba to call VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
600594 -            and schedule another meeting on managing lipids; called and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
600595 -            scheduled meeting with Doctor Rao, an attending physician,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
600596 -            on 141024 0830. ref SDS A8 8E5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
600598 -             ..
600599 -            [On 141022 1523 Doctor Rao called and changed the time of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
600600 -            the meeting from 0830 to 0900 on 141024. ref SDS B0 IF5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
600601 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
600602 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
600604 -  ..
6007 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
6008 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
6009 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
6010 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
6011 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
601101 - Lab on 131015, showing cholesterol remained high, 131015 0724,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601102 - ref SDS 56 BE6O, conflict with increased exercise and weight loss,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601103 - discussed in the letter to the medical team yesterday on 131016 1632.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601104 - ref SDS 57 IW57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601106 -  ..
601107 - On 131017 1000 VA medical chart Progress Notes assessment report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601108 - patient status CAD stable, asymptomatic. hyperlipidemia not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601109 - controlled. ref SDS 58 T24N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601111 -  ..
601112 - On 131017 1000 Doctor Egan proposed referring patient for clinical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601113 - trial to reduce cholesterol with new "targeted" drugs. ref SDS 58 179N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601115 -  ..
601116 - On 131017 1000 VA medical chart Progress Notes assessment report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601117 - patient status hyperlipidemia not controlled, ref SDS 58 PSXT; Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601118 - Egan makes referral to SF VA Medical Center for consult on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601119 - participation clinical trials, ref SDS 58 EU9F, with experimental                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601120 - agents such as AMGEN 145 and REGN 727 to resolve multiple statin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601121 - intolerance. ref SDS 58 CN4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601123 -  ..
601124 - On 131103 received letter from VA SF Medical Center scheduling meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601125 - on 131121 1000, to consider clinical trial for lowering cholesterol.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601126 - ref SDS 60 YT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601128 -  ..
601129 - On 131112 New York Times published several articles reporting that the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601130 - day before on 131113, American Heart Association published new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601131 - guidelines for treating CAD patients that expand use of statin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601132 - medication regardless of cholesterol levels, ref SDS 61 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601133 - further raise the LDL 70 to LDL 190, as a target for cardiovascular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601134 - risk. ref SDS 61 CW6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601136 -  ..
601137 - On 131114 New York Times published several articles reporting that the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601138 - day before on 131113, American Heart Association published new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601139 - guidelines for treating CAD patients. ref SDS 62 SH6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601141 -  ..
601142 - On 131121 1604 meeting with Doctor Alba at San Francisco Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601143 - Center - prescribed Atorvastatin 20 mg 4-week trial and evaluate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601144 - adding Zetia 10 mg, schedule follow up on 131219 0930. ref SDS 63 6H6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601146 -  ..
601147 - On 131121 1604 in another record later today, VA prescription RX #                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601148 - 5674471 for Atorvastatin 20 mg has been ordered. ref SDS 65 GH5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601150 -  ..
601151 - On 131125 0005 letter from Karen reports VA work plan to take statin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601152 - drug low dose Atorvastatin 10 mg for 4 weeks, then add Zetia 10 mg in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601153 - clinical trial for lowering cholesterol. ref SDS 67 V154                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601155 -  ..
601156 - On 131125 0005 research seems to indicate this clinical trial of low                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601157 - dose Atorvastatin 10 mg with Zetia 10 mg has lowered cholesterol LDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601158 - 70.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601160 -  ..
601161 - On 131205 1448 received new prescription for Atorvastatin 20 mg,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601162 - ordered by Doctor Alba today for 4-week trial to assess side effects                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601163 - for adding 2nd drug, Zetia 10 mg to lower LDL 249. ref SDS 68 GH5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601165 -  ..
601166 - On 131216 0028 letter to Doctor Alba submit agenda for meeting at VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601167 - SFMC on 131219. ref SDS 69 HY6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601169 -  ..
601170 - On 131219 0930 meeting Doctor Alba at San Francisco VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601171 - ordered Ezetimibe 10 mg prescription for adding to Atorvastatin, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601172 - ordered blood test to evaluate changes in lipid profile. 131219 0930,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601173 - ref SDS 70 NJ6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601175 -  ..
601176 - On 131230 1450, received Ezetimibe in US mail, ref SDS 71 5N3O,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601177 - ordered by Doctor Alba on 131219, 131219 0930, ref SDS 70 6H6K; begin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601178 - trial to manage cholesterol with Atorvastatin 10 mg and Ezetimibe 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601179 - mg, planned during meeting at VA on 131121 0930. ref SDS 63 6H6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601181 -  ..
601182 - On 140114 0845 letter to Diana request Progress Notes meeting 131219,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601183 - ref SDS 72 HY6O, and ask about expanding scope pending lab to include                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601184 - LDL-P. ref SDS 72 2140                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601186 -  ..
601187 - On 140115 1842 letter Diana will look for Progress Notes meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601188 - 131219, ref SDS 73 HY6O; investigating prospects for ordering lab test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601189 - LDL-P, ref SDS 73 CE80; VA claims patient cholesterol and LDL are above                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
601190 - target. ref SDS 73 CE91  VA further claims testing LDL-P not effective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601191 - in this case because LDL-C is not optimal. ref SDS 73 FF4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601193 -  ..
601194 - On 140116 0814 letter thanks Doctor Alba for investigating to find                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601195 - Progress Notes for meeting at VA on 131219. ref SDS 74 HY6O  Cite                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601196 - research indicating patient with discordant LDL-C high and LDL-P low,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601197 - shown in patient lab on 131015, constitutes least risk for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601198 - arteriolosclerosis disorder, CVD, myocardial infarction. ref SDS 74 735Y                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601200 -  ..
601201 - On 140128 1327 letter asks again about Progress Notes meeting 131219,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601202 - ref SDS 75 HY6O; report hiking 11 miles per day continued, weight hit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601203 - 165, ref SDS 75 TZ8U; ask where to get lab at VA Martinez, in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601204 - Francisco, or at UCSF. ref SDS 75 TZ96  No side effects from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601205 - Atorvastatin and Ezetimibe. ref SDS 75 TZ99                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601207 -  ..
601208 - On 140131 0815 have not received instructions from VA on getting lab                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601209 - to test LDL-P, so ordered test. ref SDS 76 OO5G lab blood draw at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601210 - Labcorp in Walnut Creek on Ygnacio Valley Road. ref SDS 76 NT6T                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601212 -  ..
601213 - On 140201 1159 obtained blood draw for Lipid NMR test at Labcorp on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601214 - Health Testing Centers order # 27716, ref SDS 77 KQ4L, showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601215 - "concordance" LDL-P 861, LDL-C 81, HDL 61, TG 68, LDL (pattern A) size                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601216 - = large buoyant protective. ref SDS 77 IM9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601218 -  ..
601219 - On 140203 1147 VA blood draw at Martinez clinic to cross check Labcorp                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601220 - blood test. 140203 1147, ref SDS 78 KK9M, showing LDL-C 93, HDL 58, TG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601221 - 47, ref SDS 78 IM9N, indicating "concordance" LDL-P 626, LDL (pattern                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601222 - A) size = large buoyant protective. ref SDS 78 QV5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601224 -  ..
601225 - On 140204 1236 letter from VA today, notifies that Progress Notes for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601226 - meeting on 131219, have been posted and are available for customer to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601227 - receive from ROI department. ref SDS 79 HY6O  Cause for 6-weeks delay                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601228 - issuing Progress Notes not clear in the record. ref SDS 79 V44F  VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601229 - Progress Notes for meeting on 131219, are comprehensive and helpful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601230 - ref SDS 79 MR3G  Progress Notes have many minor grammatical errors                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601231 - likely due to limited time, ref SDS 79 MZ5H, VA does not support NMR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601232 - lipid tests to determine LDL-P and discordance with LDL-C; patient can                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601233 - obtain test from another lab. ref SDS 79 CE80  VA letter today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601234 - maintains discordance with low LDL-P and high LDL-C is "unhealthy" -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601235 - submits no evidence from medical literature supporting this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601236 - proposition, nor to address literature submitted to the VA stating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601237 - discordance is the healthiest condition for CVD patients. ref SDS 79                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601238 - 6U4L  VA concurs that lowering weight toward BMI standards aids                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601239 - resolving hyperlipidemia. ref SDS 79 8N9H  VA maintains lifestyle                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601240 - through exercise and diet to control weight and hyperlipidemia require                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601241 - support taking statin medications, e.g., Atorvastatin and Ezetimibe.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601242 - ref SDS 79 GT5F  VA letter today says patient mis-reads literature on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601243 - discordance between LDL-P and LDL-C, and proposes discussions to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601244 - clarify this matter during meeting scheduled on 140213. ref SDS 79 HU5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
601245 - VA prefers patient get labs drawn at San Francisco VA Medical Center.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601246 - ref SDS 79 PT3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601248 -  ..
601249 - On 140211 0133 letter submits agenda to VA for meeting scheduled on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601250 - 140213. ref SDS 80 HY6O  Progress Notes on 131219 received from VA on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601251 - 140204 1236. ref SDS 79 HY6O, stating LDL-P provides stronger                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601252 - association with CVD risk, ref SDS 70 GO35, and VA letter saying                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601253 - patient can support the team with NMR lab, reported on 140204 1236.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601254 - ref SDS 79 CE80, was implemented on February 1 using Labcorp.  VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601255 - request to have lab at San Francisco reported on 140204 1236.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
601256 - ref SDS 79 PT3M, was received the day after lab was drawn at Martinez.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601257 - Will do VA labs in San Francisco for next cycle. ref SDS 80 TU68                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601259 -  ..
601260 - On 140211 0133 letter notifies VA consolidated patient history shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601261 - strong alignment, ref SDS 80 TV31, between NMR test on 140201, and VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601262 - lipid panel 2 days later on 140203. ref SDS 78 IM9N  Low LDL-P 861                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601263 - concordant with low LDL-C 81 in Labcorp NMR report on 140201.  TG 47                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601264 - and HDL 58 in VA lab 2 days later on 140203 1147, ref SDS 78 5C7M,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601265 - aligns with Labcorp results. ref SDS 80 TV3M  Labcorp further shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601266 - LDL size 21.3 is "pattern A", indicating large, buoyant LDL particles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601267 - "protect" against CVD.  While research indicates discordance with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601268 - LDL-P low and LDL-C high is the healthiest cardiovascular condition                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601269 - shown on 131125 0005, ref SDS 67 FI3G, and submitted to the VA in a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601270 - letter on 140116 0814, ref SDS 74 H29T; and previously cited in a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601271 - prior letter on 140114 0845, ref SDS 72 2140, patient healthy and very                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601272 - grateful for outstanding care by entire VA team. ref SDS 80 TV3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601274 -  ..
601275 - On 140211 0133 letter notifies VA lab on 140203 improving prior lab on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601276 - 131015, ref SDS 80 TV40, resulted from Atorvastatin 40 mg - 4 weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601277 - beginning on 131121, shown in case study on 120101 0900, ref SDS 29                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601278 - RN3F, then Atorvastatin 10 mg and Ezetimibe 10 mg beginning on 131230,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601279 - also in case study, ref SDS 29 6A6H, making total for 8 weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601280 - Atorvastatin 1850 mg, Ezetimibe 340 mg; as well, hiking 933 miles,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601281 - weight loss to 165, low-carb diet, chia seeds, orange juice, as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601282 - further set out in the record for the lab at the VA on 140203.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601283 - ref SDS 78 I17G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601285 -  ..
601286 - On 140211 0133 letter notifies VA lab on 140203 shows potassium (K 5.4)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601287 - is elevated again, ref SDS 80 TV5F, and T Bilirubin 2.1 further                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601288 - increased again, while Labcorp shows these are stable. ref SDS 78 ZG5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601290 -  ..
601291 - On 140213 0830 meeting at VA Medical Center in San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601292 - ref SDS 81 195I, good progress lowering risks of CVD based on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601293 - concordant low LDL-P 861 with low LDL-C 81. shown by lab NMR lipid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601294 - panel. ref SDS 81 TB6J  Medical team excellent results collaborating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601295 - doctor/patient partnership. ref SDS 81 1L7M  Atorvastatin 40 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601296 - started 131121, and then changed to Atorvastatin 10 mg with Ezetimibe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601297 - 10 mg started 131230. ref SDS 81 IE7F  No side effects taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601298 - medication. ref SDS 81 333L  Discordance between LDL-P and LDL-C                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601299 - discussed. ref SDS 81 WM8J  Continue medication, diet, exercise and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601300 - weight loss protocols, and test lipid panel again in 3 months on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601301 - 140519 0800. ref SDS 81 8X5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601303 -  ..
601304 - On 140213 0830 meeting at VA Medical Center in San Francisco request                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601305 - test for regression of atherosclerosis plaque using coronary CTA to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601306 - evaluate CVD risk which 5 years earlier required surgery in 2009.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601307 - ref SDS 81 JZ4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601309 -  ..
601310 - On 140213 0830 Progress Notes for meeting at VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601311 - Francisco have numerous errors, e.g., failing to report hiking 933                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601312 - miles that lowered Triglycerides and raised HDL to reduce CVD risk                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601313 - through regression of atherosclerosis. ref SDS 81 O55H  VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601314 - representation that LDL "still not at goal" conflicts with the record,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601315 - and fails to present the "goal" and the authority that supports it.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601316 - ref SDS 81 WF5J  VA representation that total cholesterol and LDL-C                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601317 - are above target conflicts with the most recent lab showing both labs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601318 - are below target. ref SDS 81 5I7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601320 -  ..
601321 - On 140213 0830 Progress Notes for meeting at VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601322 - Francisco state LDL-P has stronger association with cardiovascular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601323 - risk than LDL-C. ref SDS 81 S35H  Patient LDL-P 861 with Labcorp test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601324 - on 140201, is "optimal" - 150 points lower target of 1000 for minimal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601325 - CVD risk, shown in consolidated lab on 140203. ref SDS 78 BE6O  VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601326 - representation that patient LDL-C is not at optimal levels conflicts                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601327 - with VA record of lab tests on 140203 1147, ref SDS 78 BE6O, and is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601328 - otherwise not supported by reference to recognized authority.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
601329 - ref SDS 81 S35H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601331 -  ..
601332 - On 140213 0830 Progress Notes for meeting at VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601333 - Francisco Plan of care prescribes continue physical activity and low                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601334 - fat/low cholesterol diet. ref SDS 81 E34O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601336 -  ..
601337 - On 140226 1332 letter to VA transmits notes of meeting on 140213.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601338 - ref SDS 82 HY6O  Report cold symptoms side effects taking Atorvastatin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601339 - with Ezetimibe. ref SDS 82 JY8K  Request coronary CTA radiology test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601340 - regression atherosclerosis. ref SDS 82 JR99  Request Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601341 - meeting on 140213. ref SDS 82 JY4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601343 -  ..
601344 - On 140303 1644 letter to VA reports recovery from symptoms of cold,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601345 - which may indicate this was not caused by prescribed medication side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601346 - effects taking Atorvastatin and Ezetimibe. ref SDS 83 HY6O  Letter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601347 - requests Progress Notes for meeting a few weeks ago at Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601348 - in San Francisco, and because Release of Information (ROI) department                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601349 - at the VA Clinic in Martinez has been delayed issuing patient medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601350 - records. ref SDS 83 E788                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601352 -  ..
601353 - On 140305 1117 letter to VA follows up asking about work plan in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601354 - Progress Notes doing CT and other testing to evaluate regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601355 - atherosclerosis, ref SDS 84 WY3X, since CABG x4 surgery on 091022                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601356 - 0700. ref SDS 15 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601358 -  ..
601359 - On 140307 1509 letter notifies VA that Ezetimibe and Atorvastatin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601360 - prescription refill not delivered, and so treatment is paused pending                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601361 - delivery. 140307 1509, ref SDS 85 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601363 -  ..
601364 - On 140307 1509 at 1730 VA letter reports plans to investigate to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601365 - resolve delayed delivery of prescription refill for Atorvastatin and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601366 - Ezetimibe. ref SDS 85 MS9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601368 -  ..
601369 - On 140308 0956 another letter asking VA to investigate delayed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601370 - delivery medication refills. ref SDS 86 II91                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601372 -  ..
601373 - On 140310 0939 another letter to VA requests assistance again                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
601374 - resolving delayed delivery medication refills for Atorvastatin and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601375 - Ezetimibe. ref SDS 87 LS88  On 140310 0939 at 1121 VA letter responds                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601376 - to letter sent at 0939, and asks if medication refills have been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601377 - delivered for Atorvastatin and Ezetimibe. ref SDS 87 VP4J  At 1156                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601378 - notified VA have not received medication. ref SDS 87 345R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601380 -  ..
601381 - On 140311 1730 received prescription refill for Atorvastatin and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601382 - Ezetimibe, delivered by neighbor because mailman delivered to the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601383 - wrong mailbox; treatment resumed. ref SDS 88 YS4O  At 1903 notified VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601384 - medication refill was received, so treatment resumed. ref SDS 88 KF5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601386 -  ..
601387 - On 140312 1720 letter to VA Medical Center in San Francisco submits                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601388 - comments on Progress Notes for meeting on 140213. ref SDS 89 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601389 - Recommend corrections to avoid propagating errors forward when current                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601390 - Progress Notes are used to expedite making Progress Notes for the next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601391 - meeting scheduled on 140519. ref SDS 89 IL83                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601393 -  ..
601394 - On 140312 1720 letter to VA Medical Center in San Francisco submits                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601395 - question on goals for HDL and TG to lower LDL-P that has the strongest                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601396 - association with CVD risk, ref SDS 89 IL4M, cited in VA Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601397 - on 131219, ref SDS 70 GO35, and restated in Progress Notes for meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601398 - on 140213 0830. ref SDS 81 S35H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601400 -  ..
601401 - On 140312 1720 letter to VA Medical Center in San Francisco requests                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601402 - guidance in Progress Notes on goals for diet and exercise that yielded                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601403 - dramatic rise in HDL 21% and reduction of TG 60%, given that research                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601404 - indicates Atorvastatin and Ezetimibe have been found to increase HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601405 - 5%-9%, and lower TG 30%-40% [...reported on 131125 0005. ref SDS 67                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601406 - PU6I...] - see AHA article Circulation published 030428...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601408 -  ..
601409 - On 140312 1720 letter to VA Medical Center in San Francisco requests                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601410 - testing for regression of atherosclerosis that lowers CVD risk based                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601411 - on labs showing elevated HDL in combination with low TG, ref SDS 89                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601412 - PSXX, discussed during the meeting on 140213 0830, ref SDS 81 JZ4O,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601413 - citing research on 131125 0005. ref SDS 67 E13K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601415 -  ..
601416 - On 140430 0900 at 0400 letter to Doctor Egan Cardiology VA Clinic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601417 - Martinez agenda for meeting 0900, ref SDS 91 HY6O, report patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601418 - history of lipid labs, ref SDS 91 PT53, may show discordance with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601419 - LDL-P low and LDL-C high, indicating low risk CVD. ref SDS 91 PT6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601421 -  ..
601422 - On 140430 0900 at 0400 letter to Doctor Egan Cardiology VA Clinic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601423 - Martinez agenda meeting at 0900 reported maintained training protocol                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601424 - hiking 11 miles daily, along with low-carb diet training for hiking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601425 - Half Dome on 140917.  Weight has reached 164, as shown in patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601426 - history, but is most often about 170 after hiking. ref SDS 91 PU34                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601428 -  ..
601429 - On 140430 0900 at 0900 meeting Doctor Egan Cardiology VA Clinic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601430 - Martinez discussed CTA imaging tests to assess regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601431 - atherosclerosis plaque, ref SDS 91 2F6O, that required CABG +4 on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601432 - 091022 0700, ref SDS 15 PQWU, as considered previously with the VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601433 - during the meeting in San Francisco on 140213 0830, ref SDS 81 JZ4O,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601434 - and cited in the letter on 140312 1720. ref SDS 89 PSXX  Doctor Egan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601435 - seemed to indicate that patient history of CABG +4 surgery 5 years ago                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601436 - on 091022, makes evaluating regression of atherosclerosis unnecessary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601437 - to adjust prescribed care of medication and extended exercise for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601438 - purpose of saving and money, and reducing painful side effects.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601439 - ref SDS 91 OK7L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601441 -  ..
601442 - On 140430 0900 meeting Doctor Egan Cardiology VA Clinic Martinez                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601443 - reported hiking stresses left knee injured in a fall of 40' back in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601444 - 1973, causing degenerative arthritis.  In past month or so, feet have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601445 - begun to hurt, so it remains a challenge to control CVD risk through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601446 - exercise.  Glucosamine Chondroitin helps resolve some of this problem,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601447 - with the result that hiking this year is about 300 miles ahead of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601448 - record hiking through the 1st 4 months of last year. ref SDS 91 PU37                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601449 - Doctor Egan encouraged extended endurance hiking for lowering LDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601450 - cholesterol and triglycerides and raising HDL that reduce CVD risk.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601451 - ref SDS 91 RI9N   The doctor asked about resting heart rate,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601452 - ref SDS 91 297N, this has reduced to below 60, due to increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601453 - endurance hiking, shown from patient history beginning on 140422,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601454 - shown in case study on 120101 0900. ref SDS 29 RQ6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601456 -  ..
601457 - On 140430 0900 meeting Doctor Egan Cardiology VA Clinic Martinez                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601458 - reported slight and occasional dizziness when laying down and turning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601459 - my head. ref SDS 91 PU43  Overall health very good.  CT study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601460 - 130117 showed esophagus has finally returned to normal, without the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601461 - big bubble that was there for 5 years or so.  Accordingly, VA has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601462 - provided outstanding health care. ref SDS 91 PU47                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601464 -  ..
601465 - On 140430 0900 letter from Doctor Egan, Cardiology Physician at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601466 - Martinez Clinic, notes medical team did not address elevated potassium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601467 - in labs, and again notifies that this condition represents exposure to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601468 - "electrical problems" with the heart. ref SDS 91 UV5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601470 -  ..
601471 - On 140505 0936 Doctor Egan notified that medical team at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601472 - Center in San Francisco was advised of concerns on elevated potassium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601473 - (K) and Total Bilirubin, ref SDS 92 YV4L, shown in labs reported in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601474 - the record on 140203 1147. ref SDS 78 ZG5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601476 -  ..
601477 - On 140508 1133 lab for VA from Labcorp at John Muir Clinic shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
601478 - glucose, sodium at high end of range, and shows potassium and T bili                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601479 - above range, ref SDS 93 WJ5H, indicating influence of extended                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601480 - endurance hiking 22 miles the day before, and another 11 miles morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601481 - of the blood draw, and possibly caused by statin and ezetimibe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601482 - treatment to lower LDL cholesterol, as discussed in Notes of the lab                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601483 - on 140508 1133. ref SDS 93 G34G  Lipid panel shows further improvement                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601484 - with LDL-P 851 down 10 points and HDL 67 up 6 points from 4 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601485 - earlier. ref SDS 93 BE6O  Improved lipid history, ref SDS 93 W25L,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
601486 - reveres prior history of worsening lipids occurring after significant                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601487 - improvement, and is attributed to increased endurance hiking 300 miles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601488 - per month and adding orange juice at approximately 500 ml per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601489 - ref SDS 93 I17G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601491 -  ..
601492 - On 140514 0950 lab at VA Medical Center in San Francisco to support                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601493 - meeting with Doctor Alba on 140519. ref SDS 94 X45G  Excellent lipid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601494 - lab, ref SDS 94 IM9N, aligns with Labcorp blood test using NMR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601495 - technology last week on 140508 1133. ref SDS 93 5C7M  Reflects                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601496 - increased hiking and weight control past 3.5 months, reported in case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601497 - study on 120101 0900, ref SDS 29 PYXR, and supported with low carb                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601498 - diet (including orange juice) and low dose medication, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601499 - 140513, in the same study. ref SDS 29 ZU5G  Favorable results seemed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
601500 - "too good to be true" and so the VA lab did a second test to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601501 - corroborate findings shown by (a) and (b) scores. ref SDS 94 5C7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
601503 -  ..
601504 - On 140515 2043 letter to VA submits consolidated results of Labcorp                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601505 - test on 140508 with VA test on 140514, noting continued favorable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601506 - lipid panel improves patient history past 3 years of worsening results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601507 - after significant improvement. ref SDS 95 1V6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601509 -  ..
601510 - On 140515 2043 letter to VA submits reports meeting with Doctor Egan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601511 - in Cardiology at Martinez Clinic on 140430. ref SDS 95 YM67  After the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601512 - meeting, the doctor wrote a letter noting again that potassium (K) was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601513 - elevated in lab on 140203, and cited risk of "electrical problems" for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601514 - CAD patients (see line 392120. ref SDS 91 UV5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601516 -  ..
601517 - On 140515 2043 letter to VA reports that on 140513, weight dropped to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601518 - 163, lowest in 30 years, after hiking another 1000 miles since prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601519 - labs in February, ref SDS 95 YM82, see case study (see line 105253                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601520 - shown on 120101 0900. ref SDS 29 PYXR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601522 -  ..
601523 - On 140515 2043 letter to VA reports medication side effects slight                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601524 - dizziness in past month when laying down and turning my head left or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601525 - right.  There may also be increased urination the past month or so,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601526 - but this is hard to track.  Seem to be getting up a lot during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601527 - night, as occurred with Rosuvastatin, but could be imagination - not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601528 - sure yet. ref SDS 95 YM98                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601530 -  ..
601531 - On 140515 2043 letter to VA requests coronary CTA with calcium score                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601532 - to evaluate regression of atherosclerosis. ref SDS 95 YM41  Further                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
601533 - requests EPC lab to assess favorable conditions along with elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
601534 - HDL for regression of atherosclerosis. ref SDS 95 YM61                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601536 -  ..
601537 - On 140515 2043 letter to VA reports labs show excellent care at the VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
601538 - achieving favorable results lowering CVD risk for continuing cycles.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
601539 - As noted initially, in past years, whenever HDL increased and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
601540 - Triglycerides dropped, on the next test the numbers got worse, see                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601541 - patient Lipid History Trend Analysis on 140508 (line 610726.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
601542 - ref SDS 94 W25L  Thanks to skill and persistence of the VA medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
601543 - team, this time the numbers improved. ref SDS 95 YM64                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601545 -  ..
601546 - On 140518 2120 letter submits agenda to Doctor Alba for meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601547 - tomorrow on 140519, at VA Medical Center in San Francisco. ref SDS 96                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601548 - 1V6M  Medication side effects of dizziness seems to have subsided.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601549 - ref SDS 96 DV50  Very dry mouth in the night past week, and frequency                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601550 - of urination has further increased, indicating dehydration issue,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
601551 - possibly associated with elevated bilirubin. ref SDS 96 DV56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601552 - Peripheral neuropathy has returned, possibly related to bilirubin.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
601553 - Follows prior pattern with Rosuvastatin, but at this time the problem                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601554 - is very minor, only a few occasions the past 2 weeks or so.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
601555 - ref SDS 96 DV59                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
601556 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601557 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601558 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601559 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
601561 -  ..
6016 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
6017 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
6018 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
6019 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
6020 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602001 - Lab Electrolytes Cross Check Potassium T Bili Doctor Egan Request                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602002 - Potassium T Bili Lab Cross Check Electrolytes Request Doctor Egan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602003 - 
602004 - Follow up ref SDS 96 DV4M, ref SDS 95 YM7H.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602005 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602006 - Doctor Alba advised there wasn't enough time to read the letter to the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602007 - VA on 140515, ref SDS 95 YM7H, reporting Doctor Egan's request in a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602008 - letter on 140430, for follow up lab to re-check electrolyte panel,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602009 - ref SDS 91 UV5I, with primary concern about elevated potassium that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602010 - can cause electrical problems with the heart. ref SDS 91 UV5Y  As a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602011 - result of a hectic schedule preventing timely review of the record,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602012 - the doctor's letter yesterday on 140518, notified that the VA decided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602013 - not to do an electrolyte lab, ref SDS 96 RW7O, responding to patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602014 - letter also yesterday on 140518, ref SDS 96 DV4M, asking again about                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602015 - following up on Doctor Egan's request on 140430, for a Chem Profile                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602016 - (electrolytes) lab. ref SDS 91 UV5Y                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602017 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602018 -            [On 140929 1418 received letter from Doctor Alba to call VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602019 -            and schedule another meeting on managing lipids; called and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602020 -            scheduled meeting with Doctor Rao, an attending physician,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602021 -            on 141024 0830. ref SDS A8 8E5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602023 -             ..
602024 -            [On 141022 1523 Doctor Rao called and changed the time of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602025 -            the meeting from 0830 to 0900 on 141024. ref SDS B0 IF5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602027 -  ..
602028 - This morning during the meeting we reviewed the record presented in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602029 - the letter on 140515 2043. ref SDS 95 1V6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602031 -  ..
602032 - Doctor Alba was pleased that Labcorp included electrolytes in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602033 - recent lab on 140508.  She indicated Labcorp results appear skewed by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602034 - patient physical activity hiking 22 miles the day before and another                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602035 - 11 miles in the morning before the blood draw, reported in the letter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602036 - to the VA on 140515 2043, ref SDS 95 YM79, possibly causing Labcorp                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602037 - test for potassium (K) 5.6 to actually increase from 5.4 even farther                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602038 - above the range of 4.8 in prior VA lab on 140203, ref SDS 93 ZG5O, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602039 - which was the cause of Doctor Egan's concern in the letter on 140430.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602040 - Doctor Alba also indicated that case management is faster and easier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602041 - for comprehensive care when patient history can be accessed directly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602042 - on the VA computer system, rather than rely on results from outside                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602043 - labs, like Labcorp.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602045 -  ..
602046 - As a result, she wants the patient to avoid physical exercise, in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602047 - particular stand down on 11 mile daily hikes until after the next lab.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602048 - She will order a Chem Profile (electrolytes) lab to check skewed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602049 - results for glucose, sodium, potassium and T Bilirubin in the Labcorp                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602050 - lab on 140508, as shown with results for VA lab on 140514, which for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602051 - some reason omitted the electrolytes (Chem Profile panel). ref SDS 94                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602052 - KK9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602054 -             ..
602055 -            [On 140520 0732 letter to Doctor Alba requesting notice                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602056 -            that order has been placed for follow up lab for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602057 -            electrolytes at the VA Medical Center prior to driving into                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602058 -            San Francisco. ref SDS 97 YW4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602060 -             ..
602061 -            [On 140520 0732 at 0812 letter from Doctor Alba notifying                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602062 -            that order for electrolytes lab will be issued OA 0845.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602063 -            ref SDS 97 4V5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602065 -             ..
602066 -            [On 140520 0732 at 1017 VA lab Chem Profile shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602067 -            electrolytes generally improved - potassium (K) 5.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602068 -            declined from 5.6 on Labcorp test on 140508, and from 5.4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602069 -            in VA lab on 140203 - additionally, glucose 98 declined                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602070 -            from 103, sodium 139 declined from 144, and T Bil 1.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602071 -            declined from 2.2. ref SDS 97 ZG5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602072 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602073 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602075 -  ..
602076 - VA Success Managing Cholesterol for Regression Atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602077 - Hyperlipidemia Cholesterol Controlled Exercise Diet Medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602078 - Cholesterol Managed Clinical Trial Exercise Diet Medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602079 - Clinical Trial Considered Lower Cholesterol Without Statin Drugs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602080 - 
602081 - Follow up ref SDS 81 HY6O, ref SDS 70 HY6O.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602082 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602083 - Doctor Alba very pleased LDL-P 851 dropped well below the target of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602084 - 1000 for good cholesterol health, indicating effective lipid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602085 - management for cardiovascular health.  Equally critical HDL 67                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602086 - increased again, and together with triglycerides (TG) 58 yield TG/HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602087 - ratio 0.88 that enables rapid regression of atherosclerosis, shown in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602088 - the record consolidating Labcorp test on 140508 with VA lab yesterday                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602089 - on 140514 0950. ref SDS 94 IM9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602091 -  ..
602092 - During the prior meeting on 140213 0830, reviewed Doctor Alba's report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602093 - that LDL-P has the strongest association with CVD risk. ref SDS 81                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602094 - UV4O This was confirmed in VA Progress Notes for meeting on 140213.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602095 - ref SDS 81 S35H  At that time on 140213, reviewed research with the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602096 - doctor indicating lowest risk for CVD is low LDL-P and high LDL-C,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602097 - and; concomitantly the highest risk is high LDL-P and low LDL-C.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602098 - ref SDS 81 UV4O  Doctor Alba's Progress Notes for the prior meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602099 - mention reviewing this research, but do not present the actual                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602100 - findings. ref SDS 81 I35L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602102 -  ..
602103 - Today, the doctor further noted the VA lab on 140514, found LDL-C 87                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602104 - remains well below VA published goal LDL-C <= 131. ref SDS 94 5C7M
602105 - LDL-C 87 is more than 50% lower than current AHA guidelines for LDL-C                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602106 - < 190, reported on 131112 1422. ref SDS 61 HT87
602108 -  ..
602109 - Doctor Alba appreciated attribution in the letter on 140515,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602110 - commending the VA medical team for maintaining excellent lipid labs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602111 - over 2 cycles, ref SDS 95 YM64, which has not previously occurred in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602112 - patient history the past 8 years, beginning in 2006, shown in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602113 - record of Patient Lipid History on 140514. ref SDS 93 W25L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602114 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602115 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602117 -  ..
602118 - Physical Activity Hike 300 Miles Per Month Prescription Lower CVD Risk                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602119 - Weight Lowest 30 Years Prescribed Low Carb Diet and Physical Activity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602120 - Prescribed Care Implemented Rigorously through Doctor Patient Collaboration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602121 - 
602122 - Doctor Alba commended dropping weight to 163, lowest in 30 years,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602123 - after hiking 2 laps (22 miles) on 140513, reported in case study of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602124 - patient history on 120101 0900, ref SDS 29 ZU5G  She credited                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602125 - compliance with low carb diet and continuing physical activity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602126 - prescribed in Progress Notes on 140213 0830, ref SDS 81 MQ5G, for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602127 - reducing weight from 200 last year to 165 or even 160, which she                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602128 - presented during a prior meeting at the VA on 131219, 0930.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602129 - ref SDS 70 A56N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602131 -  ..
602132 - Favorable patient outcome reflects effective doctor patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602133 - partnership through strong communications, illustrated by the letter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602134 - submitted on 140515, requesting coronary CTA with calcium score to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602135 - test response to treatment for regression of atherosclerosis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602136 - ref SDS 95 YM41  Effective doctor patient collaboration at the VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602137 - aligns with standard of care for evidence based medical practice, set                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602138 - out in a letter to UCSF and Kaiser on 090725 2017. ref SDS 11 T55T                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602140 -  ..
602141 - Prescribed treatment to continue physical activity was implemented                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602142 - hiking 11 miles per day and averaging 300 miles per month shown in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602143 - patient history on daily medication, diet, vitals and exercise, listed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602144 - in case study on 120101 0900. ref SDS 29 QJ5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602146 -                ..
602147 -               Mileage 2014                       Miles     Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602148 -               
602149 -               131103....Oct................. 373     5757 ...... ref SDS 29 6F9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602150 -               131201....Nov................. 172     2899 ...... ref SDS 29 XRPV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602151 -               131229....Dec................. 234     3324 ...... ref SDS 29 XXQY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602152 -               140202....Jan................. 347     5393 ...... ref SDS 29 YWST                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602153 -               140302....Feb................. 234     3681 ...... ref SDS 29 PYWS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602154 -               140330....Mar................. 207     3313 ...... ref SDS 29 RXPR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602155 -               140427....Apr................. 310     4402 ...... ref SDS 29 RXVV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602156 -               140601....May...projected..... 322     5338 ...... ref SDS 29 SXWV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602158 -  ..
602159 - This level of endurance exercise aids weight control and lowers                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602160 - triglycerides, shown in research on 131125, ref SDS 66 U44L, which was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602161 - submitted to the VA in the letter on 140515. ref SDS 95 YM82                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602162 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602163 -            [...below on 140519 0800 Doctor Alba noted that elevated T                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602164 -            Bilirubin that may drive or compound peripheral neuropathy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602165 -            side effects of statin drugs, can also be caused by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602166 -            vigorous exercise prescribed for continuing physical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602167 -            activity to lower CVD risk. ref SDS 0 U56J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602168 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602170 -  ..
602171 - HDL 67 Increased with Sufficcient Exercise Training                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602172 - Orange Juice Clinical Trial Increases 21% with Sufficient Quantity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602173 - 
602174 - The same study reviewed on 131125, noted:  "It is now fairly well                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602175 - recognized that endurance exercise training can increase plasma HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602176 - cholesterol levels, if the exercise training stimulus is sufficient.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602177 - Furthermore, several studies have suggested that HDL-raising effect of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602178 - endurance exercise training could be largely explained by the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602179 - concomitant loss of body mass or fat." ref SDS 66 6R7O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602181 -  ..
602182 - Patient lipid history shows HDL increased from 30 to 67 following CABG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602183 - +4 cardiothroacic surgery on 091022, reported in case study on 140514                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602184 - 0950. ref SDS 94 W25L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602186 -  ..
602187 - Orange juice was also discussed during the meeting today, for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602188 - contributing to 30% rise from HDL 50 on 131015, to HDL 67 on 140514,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602189 - shown in patient history on lipid labs in the record on 140514 0950.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602190 - ref SDS 94 W25L  Doctor Alba feels this correlates with the study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602191 - reviewed on 131125 0005, ref SDS 66 K34L, and submitted to the VA in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602192 - the letter on 140515 2043, ref SDS 95 YM5N, also presented in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602193 - record reviewing favorable HDL lab results on 140514 0950. ref SDS 94                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602194 - LO4J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602196 -             ..
602197 -            [...below on 140519 0800 VA Progress Notes report patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602198 -            increased intake of orange juice; needs to show quantity of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602199 -            juice consumed in relation to rise in HDL aligns with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602200 -            published studies reporting favorable correlation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602201 -            ref SDS 0 PB4I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602203 -  ..
602204 - In this case, drinking orange juice 1 gallon (3786 ML) per week (541                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602205 - ML/day) added to diet on 131125, based on study indicating HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602206 - increased 21% over 4 weeks with 750 ml per day (i.e., 1.4 gal per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602207 - week), ref SDS 67 R48K, as reported to VA in letter on 140114 0845.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602208 - ref SDS 72 218O  Some research also indicates grape juice increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602209 - HDL; however, no studies have quantified this effect.  Patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602210 - actually drinks combination of lemon juice, orange juice, and grape                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602211 - juice in large quantities to hydrate after hiking 11 miles per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602213 -  ..
602214 - HDL 67 increase from HDL 50 = 34% rise in 6 months from Dec 2013 - May                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602215 - 2014, shown in patient history on 140514. ref SDS 94 W25L, represents                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602216 - approximately 7% for each 4 week period.  It may reflect drinking 541                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602217 - ML of orange juice rather than 750 ML per day used in the study.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602218 - Raising HDL consistently 7% over 4 weeks for 6 months taking only 541                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602219 - ML in this case, presents improved results compared to study results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602220 - finding 500 ML of orange juice for 4 weeks had no effect on HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602221 - levels.  Improved results in this case may indicate orange juice at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602222 - 540 ML/day combined with hiking 11 miles per day, discussed below,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602223 - provides a direct path to improve lipid profiles toward avoiding and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602224 - regressing atherosclerosis plaque.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602225 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602226 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602228 -  ..
602229 - Atherosclerosis Regresses Rapidly With Elevated HDL and EPCs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602230 - 
602231 - Follow up ref SDS 81 JZ4O.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602232 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602233 - Research on 131125, further found that elevated HDL cholesterol                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602234 - produced in the liver, together with circulating endothelial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602235 - progenitor cells (EPCs) produced in the bone marrow, both driven by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602236 - extended endurance exercise (e.g., running, hiking, biking, swimming),                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602237 - ref SDS 66 6O9M, are pathophysiological conditions for rapid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602238 - regression of atherosclerotic plaques, ref SDS 66 HG90, thus lowering                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602239 - CVD risk.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602240 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602241 -            [On 140520 0732 letter next day to VA requests adding EPCs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602242 -            to make-up lab, ref SDS 98 4U46, ordered by Doctor Alba for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602243 -            adding electrolytes to check for elevated potassium, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602244 -            discussion today above. ref SDS 0 VO4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602246 -  ..
602247 - Coronary CTA with calcium score provides standard of care testing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602248 - response to treatment reducing atherosclerosis plaques to evaluate CVD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602249 - risk, presented in the letter to the VA on 140515 2043, ref SDS 95                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602250 - YM41, following up discussion during the prior meeting on 140213 0830.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602251 - ref SDS 81 JZ4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602252 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602253 -            [On 140529 0942 letter to VA requests progress ordering EPC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602254 -            lab, and requests order for coronary CTA with calcium score                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602255 -            standard of care testing response to treatment for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602256 -            regression of atherosclerosis. ref SDS A1 QG38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602258 -  ..
602259 - Doctor Alba noted advantages of physical activity for lowering CVD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602260 - risk prescribed in Plan of Care for Progress Notes on 140213.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602261 - ref SDS 81 MQ5G  The doctor left the examination room to consult with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602262 - Doctor Feingold, attending.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602263 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602264 -            [...below on 140519 0800 Progress Notes work plan do not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602265 -            include continuing physical activity that has yielded                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602266 -            favorable results. ref SDS 0 OW76                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602268 -  ..
602269 - Doctor Alba and Doctor Feingold returned about 20 minutes later.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602270 - Doctor Feingold maintained that coronary CT angiography (CCTA) testing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602271 - with calcium score cannot be used with patient history of CABG +4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602272 - cardiothoracic surgery on 091022, ref SDS 15 PQWU, because patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602273 - physiology was changed in a manner and to a degree that prevents                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602274 - effective interpretation of radiology CT scan results.  He spread his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602275 - fingers and slid both hands together signifying complexity of tangled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602276 - coronary blood vessels intertwined by surgery that overwhelms medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602277 - analysis, suggesting finding plaques for CABG patients is like looking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602278 - for the proverbial "needle in a haystack."                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602280 -  ..
602281 - Controversy using CCTA radiology studies in clinical cardiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602282 - practice to assess atherosclerosis was cited in discussions at an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602283 - international conference considering prospects for HDL to regress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602284 - plaque, reported last year On 131125. ref SDS 66 1E51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602286 -             ..
602287 -            [...below on 140519 0800 VA Progress Notes cite discussion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602288 -            ordering coronary CTA with calcium score to test response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602289 -            to treatment in order and sets out explanation that such                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602290 -            testing is not standard of care for patients who have had                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602291 -            CABG surgery because heart bypass surgery changes anatomy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602292 -            ref SDS 0 OW49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602294 -             ..
602295 -            [On 140529 0942 letter to VA requests progress ordering EPC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602296 -            lab, and requests order for coronary CTA with calcium score                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602297 -            standard of care to test for response to treatment to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602298 -            achieve regression of atherosclerosis. ref SDS A1 QG38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602300 -             ..
602301 -            [On 151019 0930 CCTA with calcium score performed;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602302 -            meeting with doctor in Radiology Department reviewed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602303 -            requirements for calcium score to evaluate response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602304 -            treatment recovering from atherosclorosis. ref SDS B5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602305 -            GR4K  At the end of the meeting, the doctor agreed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602306 -            perform calcium score for comprehensive CCTA test.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602307 -            ref SDS B5 LQ5F  However, analyst's report merely says                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602308 -            "All the bypass grafts are patent." ref SDS B5 JW8O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602310 -             ..
602311 -            [On 151019 0930 addendum received on 160113, and issued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602312 -            by Doctor Priyanka Jha reports finding no evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602313 -            atherosclerosis plaque in active coronary circulatory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602314 -            system, or words to that effect. ref SDS B5 QW5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602316 -             ..
602317 -            [On 170412 1000 Doctor Simpson indicated that Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602318 -            Feingold is the resident expert on lipids. ref SDS B6 V35H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602320 -  ..
602321 - In this case, elevated coronary plaques required treatment with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602322 - surgery 5 years ago on 091022.  Subsequent treatment with elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602323 - endurance exercise the past 3 years, and increased further the past 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602324 - months, shown above, ref SDS 0 T64J, may have yielded rapid regression                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602325 - of atherosclerotic plaques.  Standard of care evaluating response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602326 - treatment for patients with history of CABG requires testing for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602327 - elevated EPCs and ordering coronary CTA with calcium score to test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602328 - for evidence of atherosclerotic plaques...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602329 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602330 -        1.  PubMed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602332 -             ..
602333 -            Cardiac CT angiography after coronary bypass surgery:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602334 -            prevalence of incidental findings.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602335 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602336 -                  http://www.ncbi.nlm.nih.gov/pubmed/17646469                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602338 -             ..
602339 -        2.  Journal of American College of Cardiology...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602340 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602341 -                  http://imaging.onlinejacc.org/article.aspx?articleID=1879181                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602343 -             ..
602344 -        3.  Computed Tomography Imaging in 2012                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602345 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602346 -                  http://books.google.ca/books?id=ASu3TUDBNCcC&pg=PA85&lpg=PA85&dq=coronary+CTA+CABG&source=bl&ots=IPn9-8gHpB&sig=iJsUE_5KAdrUjXV2kAY-Z28Rt0M&hl=en&sa=X&ei=c6asU53uBYKryATT_YGwAQ&ved=0CE8Q6AEwCA#v=onepage&q=coronary%20CTA%20CABG&f=false                                                                                                                                                                                                                                                                                                   
602347 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602348 -            ...and saying in part...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602350 -             ..
602351 -            "Coronary CTA is highly accurate for the assessment of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602352 -            coronary artery bypass graft (CABG) stenosis, and its use                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602353 -            for this purpose is endorsed by current Appropriate Use                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602354 -            Criteria.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602356 -             ..
602357 -        4.  Journal of Cardiology Cases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602358 -            Volume 5, Issue 2, April 2012, Pages e92?e95                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602360 -             ..
602361 -            Regression of coronary plaque after coronary artery bypass graft                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602362 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602363 -                  http://www.sciencedirect.com/science/article/pii/S1878540912000035                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602364 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602365 -            ...and saying in part...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602367 -             ..
602368 -            Three years after treatment, 64-MDCT showed mild stenosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602369 -            and a regression of plaque in the LMT. The mean density of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602370 -            the plaque was 73.1 HU (intermediate plaque) [...before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602371 -            CABG and 32.4 after CABG; plaque size reduced from 20.7 to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602372 -            4.26...]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602374 -  ..
602375 - Doctor Feingold seemed to say that coronary CTA tests with calcium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602376 - score are unnecessary, when there is already evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602377 - atherosclerotic plaques, based on patient history of CABG surgery in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602378 - this case CABG +4 performed 5 years ago on 091022. ref SDS 15 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602379 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602380 -            [On 140626 1652 case study showing coronary CTA common                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602381 -            medical practice evaluate response to treatment testing for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602382 -            regression atherosclerosis after CABG heart bypass surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602383 -            ref SDS A5 MZ54                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602385 -             ..
602386 -            [On 141024 0900 follow up examination Doctor Rao repeated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602387 -            policy position that CCTA does not yield reliable results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602388 -            testing response to treatment for patients who have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602389 -            undergone CABG procedure, due to surgical changes in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602390 -            anatomy. ref SDS B2 S54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602392 -  ..
602393 - The doctor further seemed to say that, since atherosclerotic plaque                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602394 - was found in this case 5 years ago during angiogram radiology testing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602395 - on 091021 0716, ref SDS 14 7L43, and required surgery the next day,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602396 - evidence based medical practice can now only rely on favorable lipid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602397 - testing, shown in the labs on 140508 and 140514, ref SDS 94 W25L, to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602398 - conclude atherosclerosis has not worsened.  He further seemed to say                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602399 - that testing for atherosclerosis after 5 years of treatment, with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602400 - coronary CTA and calcium score will not add value to current diagnosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602401 - nor aid prescription for treatment regardless of results.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602403 -  ..
602404 - No authorities, studies, published articles, nor evidence of any kind                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602405 - was cited to justify failing to test for response to treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602407 -             ..
602408 -            [...below on 140519 0800 VA Progress Notes cite discussion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602409 -            ordering coronary CTA with calcium score to test response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602410 -            to treatment in order and sets out explanation that such                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602411 -            testing is not standard of care for patients who have had                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602412 -            CABG surgery because heart bypass surgery changes anatomy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602413 -            ref SDS 0 OW49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602415 -             ..
602416 -            [On 140529 0942 letter to VA requests progress ordering EPC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602417 -            lab, and requests order for coronary CTA with calcium score                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602418 -            standard of care to test for response to treatment to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602419 -            achieve regression of atherosclerosis. ref SDS A1 QG38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602421 -             ..
602422 -            [On 140612 1048 letter from Doctor Alba says VA refuses to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602423 -            order EPC and CTA tests to evaluate regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602424 -            atherosclerosis because CABG surgery on 091022, changed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602425 -            anatomy which renders CTA test difficult, and since                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602426 -            customer has history of atherosclerosis the VA will test to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602427 -            evaluate whether the problem has been resolved, declined,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602428 -            unchanged or worsened, ref SDS A2 X45G, reflecting remarks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602429 -            by Doctor Feingold as presented in Progress Notes for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602430 -            meeting at VA on 140519 0800. ref SDS 0 OW49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602432 -             ..
602433 -            [On 141024 0900 follow up examination Doctor Rao repeated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602434 -            policy position that CCTA does not yield reliable results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602435 -            testing response to treatment for patients who have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602436 -            undergone CABG procedure, due to surgical changes in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602437 -            anatomy. ref SDS B2 S54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602439 -             ..
602440 -            [On 151019 0930 CCTA with calcium score performed;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602441 -            meeting with doctor in Radiology Department reviewed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602442 -            requirements for calcium score to evaluate response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602443 -            treatment recovering from atherosclorosis. ref SDS B5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602444 -            GR4K  At the end of the meeting, the doctor agreed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602445 -            perform calcium score for comprehensive CCTA test.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602446 -            ref SDS B5 LQ5F  However, analyst's report merely says                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602447 -            "All the bypass grafts are patent." ref SDS B5 JW8O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602449 -             ..
602450 -            [On 151019 0930 addendum received on 160113, and issued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602451 -            by Doctor Priyanka Jha reports finding no evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602452 -            atherosclerosis plaque in active coronary circulatory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602453 -            system, or words to that effect. ref SDS B5 QW5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602455 -             ..
602456 -            [On 170412 1000 Doctor Simpson indicated that Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602457 -            Feingold is the resident expert on lipids. ref SDS B6 V35H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602459 -  ..
602460 - Discussed role of testing to not merely diagnose medical problems, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602461 - also measure severity that guides treatment.  Evidence based medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602462 - practice requires testing for response to treatment.  Coronary CTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602463 - with calcium score yields results in time to make effective changes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602464 - Standard of care increases or decreases treatments, based on favorable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602465 - or adverse test findings.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602467 -             ..
602468 -            [On 140626 1652 letter notifies VA of case studies showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602469 -            failure to perform timely testing causes negative patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602470 -            outcomes. ref SDS A4 MY51  VA reference to patient having                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602471 -            vessel plaques 5 years ago, begs the question of testing to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602472 -            determine currently how much plaque, and level of care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602473 -            required, if any, to treat current condition. ref SDS A4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602474 -            MZ33  Evidence shows CTA common procedure to evaluate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602475 -            current condition post CABG surgery. ref SDS A4 MZ54                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602477 -  ..
602478 - For example, Tim Russert, well known NBC television news broadcaster                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602479 - died of heart attack despite LDL-C 68, indicating this common                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602480 - methodology of determining low CVD risk, i.e., LDL-C < 70, is not
602481 - dispositive of atherosclerosis.  As here, his doctor knew he had                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602482 - plaques, but not how much.  The patient finally had a coronary CTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602483 - which yielded an atherosclerosis calcium score of 250 that should have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602484 - been 0; however, there was not enough time to adjust line of care, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602485 - Mr Russert suffered the consequences. (see again research on 131125                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602486 - line NZ0402. ref SDS 67 N73K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602488 -  ..
602489 - Clearly, patients should be notified through timely test results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602490 - whether mere appearance of favorable indirect test results with lipid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602491 - labs, are contradicted by more direct testing of atherosclerosis with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602492 - coronary CTA, so that alternatives measures can be taken in time to be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602493 - effective.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602495 -  ..
602496 - Doctor Feingold seemed to say that since the patient has already been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602497 - treated with available pharmacology at the VA for recovering from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602498 - atherosclerosis, nothing more can be done at the VA in the event of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602499 - adverse findings.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602500 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602501 -            [On 170412 1000 Doctor Simpson indicated that Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602502 -            Feingold is the resident expert on lipids. ref SDS B6 V35H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602504 -  ..
602505 - We reviewed favorable clinical trials of new PCSK9 family of drugs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602506 - coming online, discussed previously with the VA reported in Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602507 - Notes for the meeting on 131219 0930. ref SDS 70 WF5J and ref SDS 70                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602508 - E35N  If the VA does not have time to provide available care with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602509 - promising results, the independent action can be taken.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602511 -  ..
602512 - Doctor Alba asked that since prescribed care to maintain physical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602513 - exercise at high levels has produced highly favorable results for HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602514 - 67 and TG 58, shown in VA and Labcorp labs on 140514 0950, ref SDS 94                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602515 - W25L, if a coronary CTA test showed favorable results, i.e., minimal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602516 - to no atherosclerosis plaque, even calcium score of 0, how would this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602517 - change prescribed care?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602518 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602519 -            [...below on 140519 0800 Doctor will discuss with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602520 -            colleagues ordering coronary CTA with calcium score to test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602521 -            for favorable results that support reducing prescribed care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602522 -            with medication and extended endurance training, since this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602523 -            would reduce difficult side effects. ref SDS 0 635O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602525 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602527 -  ..
602528 - Atorvastatin Ezetimibe Reduce Side Effects by Reducing Dose                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602529 - Side Effects Reduced by Reducing Treatment with Regression Atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602530 - Regression Atherosclerosis Lowers CVD Risk Reduce Treatment Reduce Side Effects                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602531 - 
602532 - Follow up ref SDS 81 A36K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602534 - Atorvastatin side effects are listed on 130603 0930. ref SDS 54 PC6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602535 - Ezetimibe side effects are listed on 131125 0005. ref SDS 67 GD8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602537 -  ..
602538 - The letter to the VA on 140515, advised of slight dizziness over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602539 - several months taking Ezetimibe may have declined past few days.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602540 - ref SDS 95 YM98  Doctor Alba was pleased with the update report in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602541 - letter yesterday that dizziness has entirely subsided, shown on 140518                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602542 - 2120. ref SDS 96 DV50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602544 -  ..
602545 - She explained that some side effects eventually go away, as the body                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602546 - adjusts to new chemistry taking foreign drugs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602548 -  ..
602549 - Urination has increased, but this is hard to track.  Seem to be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602550 - getting up a lot during the night, as occurred with Rosuvastatin, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602551 - could be imagination - not sure yet, also reported on 140515.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602552 - ref SDS 95 YM98  The letter yesterday on 140518, further clarified                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602553 - have had very dry mouth at night over the past week, and frequency of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602554 - urination has further increased, indicating dehydration issue.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602555 - ref SDS 96 DV56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602557 -  ..
602558 - Doctor Alba advised increased urination at night could reflect                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602559 - prostate issues that arise normally with aging, based on patient age                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602560 - of 69.  Recommends review with Primary Care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602562 -  ..
602563 - Peripheral neuropathy has begun to return, possibly related to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602564 - elevated bilirubin in the lab on 140514 0950. ref SDS 94 015M  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602565 - follows prior pattern with Rosuvastatin, but at this time the problem                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602566 - is very minor, only a few occasions the past 2 weeks or so, reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602567 - in the letter yesterday on 140518 2120. ref SDS 96 DV59  Background on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602568 - difficulties of elevated T bilirubin causing peripheral neuropathy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602569 - from taking statin drugs is reported in the record on 140514 0950.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602570 - ref SDS 94 G34G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602572 -  ..
602573 - Doctor Alba related making a review of patient history that shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602574 - elevated T bilirubin since 2009- prior to initiation of statin drugs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602575 - She advised this indicates elevated T bilirubin may not be caused by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602576 - taking Atorvastatin.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602577 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602578 -        Collection DT        T Bili      Range     Source                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602579 -        05/08/2014 15:28       2.5 H...0.3 - 1.2.. ref SDS A7 WJ5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602580 -        20/05/2014 10:20       1.2 ....0.3 - 1.2.. ref SDS 97 015M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602581 -        08/05/2014 11:49       1.3 H...0.0 - 1.2.. ref SDS 93 015M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602582 -        03/02/2014 09:52       2.1 H...0.3 - 1.2.. ref SDS 78 015M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602583 -        01/02/2014 12:28       1.6 H...0.0 - 1.2.. ref SDS 77 015M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602584 -        15/10/2013 08:25       1.7 H...0.3 - 1.2.. ref SDS 56 015M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602585 -        29/05/2013 08:18       1.3 H...0.3 - 1.2.. ref SDS 51 1Y9G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602586 -        28/02/2013 08:36       1.3 H...0.3 - 1.2.. ref SDS 48 6S4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602587 -        31/08/2012 15:24       2.3 H...0.3 - 1.2.. ref SDS 35 NV9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602588 -        09/05/2012 11:24       2.5 H...0.3 - 1.2.. ref SDS 33 O46K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602589 -        09/02/2012 11:18       1.8 H...0.3 - 1.2.. ref SDS 30 KK9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602590 -        17/11/2011 14:27       1.3 H.............. ref SDS 28 KK9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602591 -        13/10/2011 14:35       1.3 H.............. ref SDS 27 GM65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602592 -        27/07/2011 12:58       2.0 H.............. ref SDS 23 GM65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602593 -        07/12/2010 09:17       1.0 ............... ref SDS 22 GM65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602594 -        21/07/2010 08:54       1.3 H.............. ref SDS 18 GM65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602595 -        14/12/2009             1.3 H ............. ref DRP 1 DE4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602596 -        02/11/2009             0.9 ............... ref DRP 1 LG4L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602597 -        13/08/2009 15:09       1.7 H.............. ref SDS 12 VG8R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602599 -  ..
602600 - This record indicates T Bili high 1.7, then dropped within range at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602601 - 0.9 after heart surgery (CABG+4) on 091022.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602603 -  ..
602604 - On 131017 1000 VA Cardiology Progress Notes assessment report Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602605 - Egan concerned about chronic hyperbilirubinemia. ref SDS 59 PSXT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602607 -  ..
602608 - Today, Doctor Alba explained this record of T Bili 2.5 over 100% above                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602609 - range represents mild elevation.  She advised that vigorous exercise                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602610 - from hiking 300+ miles per month (see above, ref SDS 0 T64J), can                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602611 - increase bilirubin levels, shown in patient history discussed during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602612 - the meeting today, per above. ref SDS 0 T64J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602614 -  ..
602615 - We reviewed the record indicating that correlating elevated T Bili                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602616 - with high level of physical activity for endurance training appears                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602617 - conflicting with the record that peripheral neuropathy symptoms                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602618 - associated with elevated T bilirubin always decline within .25 miles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602619 - or so on daily 11 mile hikes, see for example the report in case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602620 - on 120101, for 140517. ref SDS 29 YW5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602622 -  ..
602623 - The doctor was pleased that other liver enzymes are within range.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602625 -  ..
602626 - She plans to follow up on elevated bilirubin issue, but did not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602627 - elaborate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602629 -             ..
602630 -            [...below on 140519 0800 VA Progress Notes confirm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602631 -            understandings that patient history shows T Bili was once                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602632 -            elevated before starting statins; plans to follow up with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602633 -            repeat lab to check liver enzymes. ref SDS 0 OW65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602635 -  ..
602636 - Doctor Alba advised that side effects should not affect prescribed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602637 - care with Atorvastatin and Ezetimibe.  She explained medical practice                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602638 - encourages patients to tolerate inconvenient side effects of effective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602639 - treatment in order to continue benefits recovering from primary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602640 - maladies like cancer, diabetes, cardiovascular disease (CVD), etc.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602642 -  ..
602643 - This conflicts with case study of Millie's care shown on 050422 1645.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602644 - ref SDS 2 OW6O  On 050514, Millie stopped treatment due to side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602645 - effects of chemotherapy. ref SDS 5 RU9M  On 050516, she notified                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602646 - Kaiser that death would be better than continuing side effects of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602647 - capecitabine.  ref SDS 6 AQ6G  However, on 050520 Mil agreed to resume                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602648 - treatment with reduced dose for capecitabine (Xeloda) to reduce side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602649 - effects, ref SDS 7 NT3I, because labs showed significant decline in CA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602650 - 15-3 cancer marker. ref SDS 7 GJ5M  Kaiser then supplemented lab work,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602651 - with a CT test that showed her cancerous nodes had shrunk so                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602652 - dramatically that the doctor advised the issue was nearly totally                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602653 - resolved, reported on 050610 1545. ref SDS 8 B58M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602655 -  ..
602656 - Standard of care at Kaiser testing with labs and radiology that proved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602657 - effective reducing the dose of treatment to lower side effects in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602658 - Millie's case might be applied in the current case at the VA.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602659 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602660 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602662 -  ..
602663 - Feet Pain Metatarsalgia Podiatry Referral Regression Atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602664 - Podiatry Resolve Metatarsalgia Feet Pain Maintain Regression Atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602665 - Atherosclerosis Podiatry Resolve Metatarsalgia Feet Pain Side Effects Physical Activity                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602666 - 
602667 - Besides possibly increasing T Bilirubin above range that might be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602668 - causing or compounding side effects of peripheral neuropathy, noted by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602669 - Doctor Alba today, per above, ref SDS 0 U56J, endurance exercise for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602670 - regression of atherosclerosis causes other side effects that compound                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602671 - degenerative arthritis in the left knee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602673 -  ..
602674 - In recent months feet have begun to hurt from reducing CVD risk                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602675 - through treatment with endurance exercise hiking 300+ miles per month,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602676 - continuing physical activity prescribed on 140213. ref SDS 81 E34O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
602677 - Glucosamine Chondroitin reduces joint pain from hiking this year about                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602678 - 300 miles ahead of the 1st 4 months of last year, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602679 - ref SDS 0 T64J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602681 -  ..
602682 - Increasing metatarsalgia pain on balls of feet due to treatment with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602683 - extended hiking was reported to Doctor Egan during a meeting in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602684 - Cardiology a few weeks ago on 140430 0900. ref SDS 91 PU37, and citing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602685 - case study on 120101 0900. ref SDS 29 PS3F  At that time on 140430,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
602686 - Doctor Egan indicated physical activity should continue in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602687 - maintain benefits of lowering CVD risk. ref SDS 91 RI9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602689 -  ..
602690 - Today, Doctor Alba also feels treatment should continue in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
602691 - maintain good results lowering CVD risks, as discussed above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602692 - ref SDS 0 A58I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602693 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602694 -            [On 140520 0732 letter to VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602695 -            Francisco cites discussion on sore feet side effects of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602696 -            hiking to lower CVD risk. ref SDS 97 UT5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
602698 -  ..
602699 - Since February have tried to resolve metatarsalgia side effects by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602700 - purchasing shoes with increased cushioning, and further ordered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602701 - resoling shoes to increase cushioning, since new shoe models seem to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602702 - have less cushioning, cited in a letter to Resole America last month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602703 - on 140408 1826. ref SDS 90 5L95                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602705 -  ..
602706 - Requested referral to Podiatry for care of metatarsalgia in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602707 - continue treatment hiking 300 miles per month that has yielded weight                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602708 - loss, lower LDL-P and triglycerides, higher HDL and EPCs that increase                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602709 - regression of atherosclerosis, thus lowering CVD risk.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602711 -  ..
602712 - Doctor Alba said to remove shoes and socks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602714 -  ..
602715 - She examined both feet to assess side effects of physical activity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602716 - treating atherosclerosis toward making referral to Podiatry for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602717 - resolution of debilitating metatarsalgia side effects.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602718 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602719 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602721 -  ..
602722 - CT Test Response Treatment Favorable Results Reduce Treatment Side Effects                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
602723 - 
602724 - We considered standard of care to reduce side effects by testing for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602725 - response to treatment using coronary CTA with calcium score,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602726 - addressing Doctor Alba's question on why test response to treatment?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602727 - ref SDS 0 467K  Favorable test results could support reducing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602728 - treatments that would in turn reduce onerous side effects of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
602729 - medication, ref SDS 0 PC8K, and endurance exercise. ref SDS 0 CC8O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
602731 -  ..
602732 - This aligns with experience at Kaiser when Doctor Johnson reduced dose                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602733 - of capecitabine chemotherapy to reduce side effects for Millie, after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602734 - testing showed that initial high dose reduced the level of detectable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602735 - cancer, reported on 050520 1045. ref SDS 7 NT3I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
602737 -  ..
602738 - Doctor Alba will discuss testing issue further with the VA team toward                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602739 - assessing viability of reducing treatment to reduce side effects based                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602740 - on evidence of improved cardiovascular health.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
602741 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602742 -            [On 151019 0930 CCTA with calcium score performed;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602743 -            meeting with doctor in Radiology Department reviewed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602744 -            requirements for calcium score to evaluate response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602745 -            treatment recovering from atherosclorosis. ref SDS B5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602746 -            GR4K  At the end of the meeting, the doctor agreed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602747 -            perform calcium score for comprehensive CCTA test.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
602748 -            ref SDS B5 LQ5F  However, analyst's report merely says                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
602749 -            "All the bypass grafts are patent." ref SDS B5 JW8O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
602751 -             ..
602752 -            [On 151019 0930 addendum received on 160113, and issued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
602753 -            by Doctor Priyanka Jha reports finding no evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602754 -            atherosclerosis plaque in active coronary circulatory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
602755 -            system, or words to that effect. ref SDS B5 QW5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
602756 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602757 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602758 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602759 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602760 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
602761 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
6028 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
6103 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610401 -  ..
610402 - Medical Chart Progress Notes Meeting 140519 VA SF Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610403 - 
610404 - Follow up ref SDS 81 476K, ref SDS 70 476K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610406 - On 140612 VA file from CD with Progress Notes for meeting on 140519                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610407 - were received through US mail from VA Medical Center in San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610408 - ROI Department for request filed on 140519.  Progress Notes were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610409 - signed on 140602. ref SDS 0 QQ5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610411 -  ..
610412 - VA Progress Notes for meeting on 140519 are stored in...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610413 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610424 -  ..
610425 - Generally, these Progress Notes correct numerous errors in past                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610426 - Progress Notes carried forward to notes for the last meeting on 140213                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610427 - 0830, ref SDS 81 3Q3N; implements request in the letter to the VA a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610428 - week or so later on 140529 0942. ref SDS A0 QF6T                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610430 -         ..
610431 -    1.  LOCAL TITLE:  ENDOCRINE-METABOLISM CLINIC F/U (MED)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610432 -        STANDARD TITLE:  ENDOCRINOLOGY OUTPATITNE NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610433 -        DATE OF NOTE:  MAY 19, 2014 @ 1300                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610434 -        ENTRY DATE:  MAY 30, 2014 @191229                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610436 -        EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610437 -        URGENCY:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610438 -        STATUS:  COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610444 -         ..
610445 -        CC:  follow up for high cholesterol                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610447 -         ..
610448 -    2.  HPI                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610449 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610450 -        1.  69 year old man with Past Medical history of CAD, s/p CABG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610451 -            in 2009, Hyperlipidemia, achalasia, s/p lap heller myotomy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610452 -            and fundoplication in 2009, here today for follow up for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610453 -            hyperlipidemia.  He was last seen in endocrine clinic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610454 -            February 2014.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610456 -             ..
610457 -        2.  He is currently on Zetia 10 mg po daily and Atorvastatin 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610458 -            mg daily.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610460 -             ..
610461 -        3.  Since his last appointment he reports multiple side effects                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610462 -            that he thinks are related to Atorvastatin.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610463 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610464 -            1.  Report dizziness when lying down and turning head-now                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610465 -                improved.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610467 -  ..
610468 - Report of "improved" dizziness side effects aligns with the letter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610469 - reporting dizziness subsided, and sent to the VA on 140518 2120.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610470 - ref SDS 96 DV50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610472 -  ..
610473 - Progress Notes should cite authority for "patient reports" so there is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610474 - an audit trail in the record that supports patient status and care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610476 -  ..
610477 - VA Progress Notes meeting 140519 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610478 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610479 -            2.  Increased urination, mostly at night.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610481 -                 ..
610482 -            3.  Dry mouth at night.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610484 -                 ..
610485 -            4.  Also c/o right foot discomfort that is usually last only a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610486 -                couple of seconds, occurs while standing or at low speed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610487 -                while hiking.  He has had 2 episodes in the past couple of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610488 -                weeks.  Mr Welch thinks right foot discomfort is due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610489 -                neuropathy; similar to what he experienced in 2012 when he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610490 -                was on Rosuvastatin.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610492 -  ..
610493 - Good report generally aligns with letter to VA on 140518.  Neuropathy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610494 - sensations in right foot "...last only a couple of seconds..." while                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610495 - standing in line.  However, when hiking this lasts about .25 miles at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610496 - current pace, which would be about 3+ minutes, and less time if pace                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610497 - is increased. (see letter to VA on 140518. ref SDS 96 DV59)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610499 -  ..
610500 - VA Progress Notes meeting 140519 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610502 -        4.  In the past couple of months, he has increased his intake                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610503 -            of orange juice.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610505 -  ..
610506 - This aligns with the letter to VA on 140515 2043, ref SDS 95 PQXS, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610507 - with discussions during the meeting, shown above. ref SDS 0 4Z8I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610508 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610509 -               [On 141024 0900 Progress Notes do not mention orange                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610510 -               juice 750 ML per day added to diet that maintained HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610511 -               while hiking declined. ref SDS B1 IO6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610513 -  ..
610514 - This section can be strengthened by citing quantity reported, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610515 - correlations between orange juice quantity, 21% rise in HDL, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610516 - clinical study results that found 21% rise in HDL reviewed on 131125                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610517 - 0005. ref SDS 66 K34L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610519 -  ..
610520 - VA Progress Notes meeting 140519 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610521 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610522 -        5.  Also he continues with vigorous exercise- hikes in average                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610523 -            11-20 miles per day a couple of times per week.  Reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610524 -            weight on May 13th was 165 pounds.  BMI 29.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610526 -  ..
610527 - VA should report patient applied Plan prescribed for care during prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610528 - meeting at the VA shown in Progress Notes on 140213 0830. ref SDS 81                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610529 - E34O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610531 -  ..
610532 - VA should cite authority for data.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610534 -  ..
610535 - Hiking a "couple times per week" conflicts with the record - this past                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610536 - year, hiking occurs every day of the week with 3 - 4 days off per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610537 - month, averaging 300 miles per month, shown in case study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610538 - medication, diet, vitals and exercise in the record on 120101 0900.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610539 - ref SDS 29 7718  This data is presented in lab reports on 140514,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610540 - which was referenced with electronic links in a letter on 140515 2043.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610541 - ref SDS 95 YM82                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610543 -            [On 140629 1921 follow up letter to VA on 140520, ordering                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610544 -            coronary CTA with calcium score, ref SDS 97 VQ48, to assess                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610545 -            reducing level of care hiking 11 miles per day in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610546 -            reduce side effects, ref SDS A6 UZ64; further request                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610547 -            referral to Podiatry for consultation to relieve                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610548 -            metatarsalgia side effects of prescribed care. ref SDS A6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610549 -            U14H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610551 -  ..
610552 - Weight reported on 140513 was 163, see case study. ref SDS 29 ZU5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610554 -  ..
610555 - This data was submitted to the VA in a letter on 140515 2043.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610556 - ref SDS 95 YM82                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610558 -  ..
610559 - Hiking mileage is also shown to reconcile improved labs in the record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610560 - on 140514 0950. ref SDS 94 I17G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610562 -  ..
610563 - VA Progress Notes meeting 140519 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610564 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610565 -        6.  Most recent labs at Labcorp and VA system showed a LDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610566 -            87-83 HDL 66-67.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610568 -             ..
610569 -        7.  Mr Welch also reports recent labs that showed elevated potassium,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610570 -            as well as elevated total bilirubin.  His cardiologist brought up                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610571 -            these issues.  Since May 2013 Potassium has ranged between                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610572 -            4.  -5.6 and T Bil between 1.3-2.1 [normal direct bilirubin].  Mr                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610573 -            Welch is concerned that this could be secondary to Atorvastatin.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610574 -            His cardiologist also considered that dehydration and vigorous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610575 -            exercise could be the cause of hyperkalemia and mildly elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610576 -            bilirubin.  Of note, review of records shows a total bilirubin of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610577 -            3.0 in October 2009- prior to initiation of statins.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610579 -  ..
610580 - Curious VA does not present addendum reporting results of chem lab                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610581 - ordered by Doctor Alba to evaluate dehydration theory, and reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610582 - 140520 0732. ref SDS 97 KK9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610584 -  ..
610585 - Citing "total bilirubin of 3.0 in October 2009 is not helpful, since                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610586 - there were many labs - actually everyday post CABG on 091022.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610587 - record on CABG was received from the VA on 100928 0706. ref SDS 19                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610588 - PG5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610589 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610590 -        Collection DT        T Bili      Range     Source                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610591 -        02/09/2012 11:18       1.8 H...0.3 - 1.2.. ref SDS 30 KK9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610592 -        11/17/2011 14:27       1.3 H.............. ref SDS 28 KK9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610593 -        10/13/2011 14:35       1.3 H.............. ref SDS 27 GM65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610594 -        07/27/2011 12:58       2.0 H.............. ref SDS 23 GM65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610595 -        12/07/2010 09:17       1.0 ............... ref SDS 22 GM65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610596 -        07/21/2010 08:54       1.3 H.............. ref SDS 18 GM65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610597 -        08/13/2009 15:09       1.7 H.............. ref SDS 12 VG8R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610598 -        11/02/2009             0.9 ............... ref DRP 1 LG4L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610599 -        12/14/2009             1.3 H ............. ref DRP 1 DE4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610601 -  ..
610602 - Cannot find lab with bilirubin 3.0 nor VA lab in October 2009?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
610604 -  ..
610605 - VA Progress Notes meeting 140519 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610606 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610607 -    3.  Pertinent history.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610609 -        1.  Patient was started on Simvastatin approximately 2-3 years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610610 -            ago, LDL at that time was around 180's - reports that his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610611 -            LDL dropped to 96 while on simvastatin, however he reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610612 -            he develop "left shoulder myopathy"- he described pain on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610613 -            his left shoulder and inability to raise it above 90                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610614 -            degrees- No CPK on records.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610616 -             ..
610617 -        2.  He was then started on Rosuvastatin 10 mg po daily and report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610618 -            that his LDL improved.  Rosuvastatin was then increased to 20 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610619 -            and he developed sexual dysfunction, dizziness, dry mouth and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610620 -            right foot numbness.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610622 -             ..
610623 -        3.  As per cardiology notes in September 2012- Rosuvastatin was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610624 -            decreased to 10mg po daily and dizziness improved, but he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610625 -            continued to complain of right foot numbness.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610627 -             ..
610628 -        4.  He now has he has been off the Rosuvastatin since 12/2012,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610629 -            and he continues to complain of right foot numbness, but he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610630 -            reports less episodes of right sole numbness with decreased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610631 -            intensity.  Of note, he was seen by neurology February 2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610632 -            for the foot numbness, Vit B12 level was within normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610633 -            range, fasting glucose level ranges from 108 to 115 mg/dl,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610634 -            Hga1c 5.5 October 2013; as per neurology notes no evidence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610635 -            of radiculopathy or neuropathy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610637 -         ..
610638 -    4.  Past Medical, Surgical, social and family history reviewed an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610639 -        unchanged                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610641 -  ..
610642 - This note reflects entry in Progress Notes para 4, PSH, for meeting at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610643 - VA on 131121 0930. ref SDS 64 W49F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610645 -  ..
610646 - Patient Medical History is shown in Progress Notes for meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610647 - Doctor Egan in Cardiology on 140430 0900. ref SDS 91 TX50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610649 -  ..
610650 - VA Progress Notes meeting 140519 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610651 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610652 -    5.  ROS- see above                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610654 -         ..
610655 -    6.  MEDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610656 -        Omeprazole 20 mg BID                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610657 -        Atorvastatin 10 mg po daily                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610658 -        Zetia 10 mg po daily                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610660 -         ..
610661 -    7.  PHYSICAL EXAM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610662 -        VS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610663 -        HT: 66 in [167.6 cm] (12/16/2009 18:00)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
610664 -        WT: 187.2 lb [85.1 kg] (05/19/2014 08:07)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610665 -        HR: 61 (05/19/2014 08:07)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610666 -        BP: 115/68 (05/19/2014 08:07)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610667 -        Temp: 97.1 F [36.2 C] (12/20/2009 08:46)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610668 -        RR: 18 (02/13/2014 08:19)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610669 -        O2 Sat: 5/19/14 08:07:12 O297                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610670 -        BMI: 30.3 (Obesity Level I)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610672 -         ..
610673 -    8.  PE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610674 -        Gen : NAD, AAO x3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610675 -        HEENT : NC/AT, MMM, PERRL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610676 -        Neck : supple.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610677 -        CARDIO : RRR, no murmurs appreciated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610678 -        LUNGS : CTA Bl, no wheezes, no rales                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610679 -        EXT : no edema, no cyanosis, no xanthemas.Normal sensations. +                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610680 -        onychomychosis in bilateral feet. Normal sensation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610682 -         ..
610683 -    9.  LABS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610684 -        May 14 2014                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610685 -        05/14/2014    CHOLESTEROL           164.00   100   - 240   PLASMA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610686 -        05/14/2014    TRIGLYCERIDE           58.00    10   - 190   PLASMA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610687 -        05/14/2014    HDL                    66.00    35   -       PLASMA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610688 -        05/14/2014    LDL CHOL(Calculated    87.00         - 131   PLASMA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610689 -        05/14/2014    HEMOGLOBIN A1C          5.40     4.0 -   6.0 SERUM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610691 -         ..
610692 -   10.  PLASMA                         ALB           TP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610693 -        [c] May 14, 2014 10:16         4.6          7.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610695 -         ..
610696 -   11.  PLASMA                         ALKP         SGOT       SGPT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610697 -        [c] May 14, 2014 10:16          93           33         27                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610698 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610699 -   12.  ********************************************************                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610701 -         ..
610702 -   13.  PLASMA                        T BIL        D BIL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610703 -        [c] May 14, 2014 10:16         2.2 H        0.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610705 -         ..
610706 -   14.  VA System                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610707 -        May 8 2014          TC 162    LDL 83    HDL 67     TG 59                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610708 -        Feb 3rd 2014        TC 160    LDL 93    HDL 58     TG 47    HgA1c 5.5%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610709 -        Labcorp             TC 156    LDL 81    HDL 61     TG 61                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610711 -         ..
610712 -   15.  October 2013        TC 321    LDL 249   HLD 50     TG 85     TBil 1.7                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610713 -        Hga1c 5.5%   CPK 110   TSH 2.6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610715 -         ..
610716 -   16.  May 2013            TC 307    LDL 240   HLD 54      TG 85    TBil 1.3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610717 -        November 2012       TC 173    LDL 105   HLD 57      TG 53    TBil 1.6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610718 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610720 -         ..
610721 -   17.  Assessment and Plan:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610722 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610723 -   18.  69 year old male with history of CAD, s/p CABG in 2009,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
610724 -        Hyperlipidemia, referred by cardiology for management of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610725 -        hyperlipidemia.  Here today for follow up.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610727 -         ..
610728 -   19.  Again improved LDL on Atorvastatin 10 mg po daily and Zetia 10 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610729 -        daily, although still not at goal on a patient with known                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610730 -        coronary artery disease and CABG.  LDL goal is less than 70mg/dL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610731 -        Explained to Mr Welch that although diet and exercise are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610732 -        important lifestyle changes in the management of hyperlipidemia,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610733 -        he needs to continue current regimen to achieve LDL goal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610735 -  ..
610736 - VA Progress Notes saying "...LDL is still not at goal," appears                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610737 - conflicting with VA lab on 140514, finding LDL-C 87, and Labcorp blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610738 - test on 140508, shows LDL-C 83, well below VA published "goal" <= 130,
610739 - and Labcorp "goal" < 100, all shown in consolidated results on 140514
610740 - 0950. ref SDS 94 W25L  Recent guidance published by American Heart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610741 - Association - AHA - shows LDL-C "goal" < 190, reported on 131112 1422.
610742 - ref SDS 61 HT87                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610743 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610744 -            [On 141106 0630 make-up lipid blood test reported LDL-C 67,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610745 -            which aligns with VA "goal" for LDL-C < 70, ref SDS B4
610746 -            U45J; however, it results from 20 unit deline in total                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610747 -            cholesterol from 156 to 137 over just 2 weeks, and so                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610748 -            conflicts with patient history of stable cholesterol for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610749 -            prior 12 months. ref SDS B4 W25L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610751 -  ..
610752 - VA should submit authority for LDL goal < 70 - presenting medical
610753 - analysis, study, etc., that justifies "goal" of LDL-C < 70?
610755 -  ..
610756 - Since LDL-P 851 was reported on Labcorp NMR test 140508, and since                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610757 - Labcorp guidance says LDL-P <1000 is the best lipid condition for
610758 - cardio vascular health shown in consolidated labs on 140514 0950,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610759 - ref SDS 94 BE6O, and since VA Progress Notes say LDL-P has stronger                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610760 - association with CVD risk than LDL-C, reported on 131219 0930,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
610761 - ref SDS 70 GO35, then why are LDL-P results not reported in Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610762 - Notes showing alignment with "goal" to lower CVD risk?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610764 -  ..
610765 - VA Progress Notes meeting 140519 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610766 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610767 -   20.  Mr Welch inquired about medical trials for PCSK9 ab.  At this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610768 -        time, there are no clinical trials at SF VA involving PCSK9.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610769 -        Patient was provided with information regarding clinical trials                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610770 -        in the bay area, in December 2013.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610772 -         ..
610773 -   21.  Mr Welch also expressed interest in CTA to assess regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610774 -        atherosclerotic plaques.  Dr Feingold explained to Mr welch that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610775 -        CTA is not used in patients that have already had CABG, since the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610776 -        anatomy has changed, and in his case we know that the many of his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610777 -        coronaries have plaques and calcifications- that being the reason                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610778 -        he needed to undergo coronary artery bypass grafting in 2009.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610780 -  ..
610781 - This aligns with discussion during the meeting this morning, where                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610782 - Doctor Feingold intertwined his fingers to illustrate tangled changes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610783 - to anatomy from CABG surgery, which he maintained prevented analysing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610784 - atherosclerotic plaques in coronary blood vessels, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610785 - ref SDS 0 J83H  For some reason, Progress Notes omit research showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610786 - coronary CTA with calcium score is standard of care to test response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610787 - to treatment for regression of atherosclerosis, per above. ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610788 - OF7N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610790 -             ..
610791 -            [On 151019 0930 CCTA with calcium score performed;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610792 -            meeting with doctor in Radiology Department reviewed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610793 -            requirements for calcium score to evaluate response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610794 -            treatment recovering from atherosclorosis. ref SDS B5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610795 -            GR4K  At the end of the meeting, the doctor agreed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610796 -            perform calcium score for comprehensive CCTA test.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610797 -            ref SDS B5 LQ5F  However, analyst's report merely says                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610798 -            "All the bypass grafts are patent." ref SDS B5 JW8O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610800 -             ..
610801 -            [On 151019 0930 addendum received on 160113, and issued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610802 -            by Doctor Priyanka Jha reports finding no evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610803 -            atherosclerosis plaque in active coronary circulatory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610804 -            system, or words to that effect. ref SDS B5 QW5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610806 -  ..
610807 - During the meeting today, Doctor Alba and Doctor Feingold further                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610808 - maintained that coronary CTA with calcium score is not standard of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610809 - care to test for regression of atherosclerosis because knowing the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610810 - severity of atherosclerosis plaques will not add any value to current                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610811 - diagnoses or treatment, per above. ref SDS 0 M16K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610813 -  ..
610814 - Controversy using CCTA radiology studies in clinical cardiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610815 - practice to assess atherosclerosis was cited in discussions at an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610816 - international conference considering prospects for HDL to regress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610817 - plaque, reported last year On 131125. ref SDS 66 1E51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610818 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610819 -            [On 141009 0900 ad hoc discussion - doctor in VA Cardiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610820 -            Department used very similar language to discourage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
610821 -            customers seeking coronary CTA with calcium score to test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610822 -            for response to treatment recovering from atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610823 -            and for the purpose of lowering risk of CVD. ref SDS A9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610824 -            AK6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610826 -  ..
610827 - These Progress Notes do not present discussions during the meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610828 - that testing to disclose severe atherosclerosis provides opportunity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610829 - to adjust treatment in time to be effective, citing well known case of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610830 - Tim Russert. ref SDS 0 6W3M  The notes do not set out representations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610831 - to the effect that alternative treatments are not available at the VA,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610832 - nor that patients are entitled to the opportunity to seek alternative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610833 - treatment, if needed, including clinical trials with PCSK9 drugs, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610834 - above. ref SDS 0 6P4I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610836 -  ..
610837 - Progress Notes further omit discussion of opportunity to reduce                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610838 - treatment in order to reduce both cost and severe side effects in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610839 - event testing finds significant regression of atherosclerosis, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610840 - above. ref SDS 0 635O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610841 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610842 -            [On 140529 0942 letter to VA requests progress ordering EPC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610843 -            lab, and requests order for coronary CTA with calcium score                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610844 -            standard of care to test for response to treatment to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610845 -            achieve regression of atherosclerosis. ref SDS A1 QG38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610847 -             ..
610848 -            [On 140612 1048 letter from Doctor Alba says VA refuses to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610849 -            order EPC and CTA tests to evaluate regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610850 -            atherosclerosis because CABG surgery on 091022, changed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610851 -            anatomy which renders CTA test difficult, and since                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
610852 -            customer has history of atherosclerosis the VA will test to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610853 -            evaluate whether the problem has been resolved, declined,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610854 -            unchanged or worsened, ref SDS A2 X45G, reflecting remarks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610855 -            by Doctor Feingold as presented in Progress Notes for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610856 -            meeting at VA on 140519 0800. ref SDS 0 OW49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610858 -             ..
610859 -            [On 140626 1652 letter notifies VA of case studies showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610860 -            failure to perform timely testing causes negative patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610861 -            outcomes. ref SDS A4 MY51  VA reference to patient having                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610862 -            vessel plaques 5 years ago, begs the question of testing to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610863 -            determine currently how much plaque, and level of care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610864 -            required, if any, to treat current condition. ref SDS A4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610865 -            MZ33  Evidence shows CTA common procedure to evaluate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610866 -            current condition post CABG surgery. ref SDS A4 MZ54                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610868 -  ..
610869 - VA Progress Notes meeting 140519 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610870 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610871 -   22.  Regarding elevated potassium, this could be secondary to vigorous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610872 -        exercise, since potassium can be released from active muscle                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610873 -        cells.  No reports of statin causing hyperkalemia.  Will plan to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610874 -        repeat potassium levels.  Instructed Mr Welch to repeat labs on a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610875 -        day that he is appropriately hydrated and avoid hiking the day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610876 -        prior to lab tests.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610878 -         ..
610879 -   23.  Review of records showed elevated total bilirubin [ with normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610880 -        direct bilirubin levels] since 2009- prior to initiation of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610881 -        statins.  Most likely mild elevation of unconjugated bilirubin is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610882 -        secondary to Gilbert's syndrome.  Gilberts' syndrome is a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610883 -        phenotypic defect that causes increase in unconjugated bilirubin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610884 -        under conditions of exertion, stress, fasting or infection and is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
610885 -        usually asymptomatic.  Also vigorous exercise can increase                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610886 -        bilirubin levels due to destruction of red blood cells.  All                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610887 -        other liver enzymes are within normal limits.  Will follow up.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610889 -  ..
610890 - This analysis aligns with understandings during the meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610891 - Doctor Alba finding patient history shows 1 slightly elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610892 - potassium lab in 2009 prior to CABG, which then declined, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610893 - increased markedly over next few years with prescription of statins                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610894 - and increased dosage, possibly reflecting progressive injury to liver.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610895 - per above. ref SDS 0 UI3F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610897 -  ..
610898 - VA Progress Notes meeting 140519 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610899 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610900 -   24.  Plan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610901 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610902 -        1.  Continue Atorvastatin 10 mg po daily and Zetia 10 mg po daily.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610903 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610904 -        2.  Weight reduction- Current BMI of 29. Encourage low fat/low                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610905 -            carbohydrate diet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610907 -  ..
610908 - Progress Notes for prior meeting on 140213 presented a Plan - "Weight                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610909 - stable, continue physical activity and low fat/low cholesterol diet."                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610910 - ref SDS 81 E34O  During the meeting today, the doctor credited                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
610911 - effective implementation of the prior plan for physical activity, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610912 - above, ref SDS 0 K77I, based on hiking 300+ miles per month, also                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610913 - above. ref SDS 0 T64J  Doctor citing elevated BMI of 29, appears                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610914 - conflicting with Progress Notes work plan today failing to continue                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
610915 - prior prescription for physical activity that yields weight loss,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610916 - favorable lipid profile, and regression of atherosclerosis that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610917 - reduces CVD risk.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610919 -  ..
610920 - VA Progress Notes meeting 140519 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610921 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610922 -        3.  Follow up Lipid panel in 4 months prior to next appointment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
610923 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610924 -        4.  Will repeat potassium and liver enzymes levels in 1 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
610926 -         ..
610927 -   25.  Patient was seen and discussed with Dr Feingold                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
610929 -         ..
610930 -   26.  Clinical Reminder Activity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610932 -         ..
610933 -   27.  MED REC NON PRIMARY CARE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
610935 -         ..
610936 -   28.  Medication Reconciliation completed, including non-VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
610937 -        medications and discrepancies, if identified, were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
610938 -        addressed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
610940 -         ..
610941 -   29.  Medication, medication changes and importance of medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610942 -        management were reviewed with the patient/caregiver.  An                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610943 -        updated list of reconciled medications has been provided to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
610944 -        the patient/caregiver.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
610946 -         ..
610947 -   30.  /es/ DIANA ALBA, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
610948 -        Endocrinology Fellow                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
610949 -        Signed: 06/02/2014 07:20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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610952 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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610971 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
610972 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
6110 -