CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
4803 -
4803 - ..
4804 - Summary/Objective
4805 -
480501 - Follow up ref SDS 36 0000. ref SDS 25 0000.
480502 -
480503 -
480504 -
480505 -
480506 -
480507 -
480509 - ..
4806 -
4807 -
4808 - Progress
4809 -
480901 - Meeting with Doctor Sandhu, following prior review with primary care
480902 - on 131209 0800. ref SDS 25 PPVY The meeting today was re-scheduled
480903 - due to scheduling error on 140815 1230. ref SDS 36 QG3I
480905 - ..
480906 - Agenda for meeting reported in the letter on 140814 2227. ref SDS 35
480907 - F06N
480908 -
480909 -
480910 -
480912 - ..
4810 -
4811 -
4812 - 0707
4813 -
481301 - Meeting Doctor Sandhu
481302 -
481303 - Follow up ref SDS 25 PPVY.
481305 - ..
481306 - The doctor received the letter to the vA on 140814 2227. ref SDS 35
481307 - F06N
481309 - ..
481310 - Doctor Sandhu reviewed the lab on 140814 1530. ref SDS 34 RP4N
481312 - ..
481313 - He noted...
481314 -
481315 - WBC 12.8 - high.............. ref SDS 34 PS6G
481316 - Lymp% 13.6 - low............... ref SDS 34 PS6G
481317 - Neut % 10.o - high.............. ref SDS 34 PS6G
481318 - SP.GRAV >=1.030 - high.............. ref SDS 34 TD4H
481319 - CL 108 - high.............. ref SDS 34 WJ5H
481320 - T. BIL 2.5 - high.............. ref SDS 34 015M
481321 - CPK (CK) - no lab
481323 - ..
481324 - Doctor Sandhu did not comment today on chronic hyperbilirubinema,
481325 - evident in T BIL 2.5 - 110% above range consistent with patient
481326 - history shown in the lab on 140814 1530. ref SDS 34 G34G There was no
481327 - discussion today of chronic hyperbilirubinemia diagnosed by Doctor
481328 - Egan in Progress Notes On 131017. ref SDS 21 PSXT
481330 - ..
481331 - Doctor Sandhu will make a referral to Dermatology for reviewing the
481332 - sore on the nose, requested in the letter on 140814 2227. ref SDS 35
481333 - K052
481334 -
481335 - [...below on 140819 0800 Progress Notes for meeting today
481336 - make referral to Dermatology for evaluation of nose sore.
481337 - ref SDS 0 5X4J
481339 - ..
481340 - Reviewed patient history of increased swallowing problems causing
481341 - increased vomitting shown in patient history in case study on 120101,
481342 - beginning on 140712. ref SDS 6 4E4M
481344 - ..
481345 - Doctor Sandhu will notify Doctor Lee in EGD Sacramento Medical Center
481346 - about increased vomitting that requires timely dilation, requested in
481347 - the letter on 140814 2227, ref SDS 35 K059, and following up work last
481348 - month to advance EGD dilation procedure reported on 140718 1017,
481349 - ref SDS 30 U87I, and which has been unsuccessful.
481350 -
481351 - [...below on 140819 0800 Progress Notes for meeting today
481352 - make referral to Doctor Lee at EGD in Sacramento Medical
481353 - Center for meeting to resolve swallowing problems.
481354 - ref SDS 0 4K5F and further at ref SDS 0 OD4Q End of
481355 - Progress Notes seem to indicate Doctor Lee has not
481356 - responded to notice. ref SDS 0 VZ5K
481358 - ..
481359 - [On 141014 0943 Kathy visited EGD Clinic at VA Medical
481360 - Center in Sacramento and talked to Lapria, who advised that
481361 - on 141001, the VA responded to the letter on 140810, saying
481362 - EGD dilation is scheduled on 141121 1500 to implement order
481363 - for 6 months after prior procedure on 140509, which would
481364 - be on 141109. ref SDS 38 NU8L
481366 - ..
481367 - Doctor Sandhu examined the blister on the left foot, requested in the
481368 - letter on 140814 2227. ref SDS 35 K055 He feels infection has
481369 - subsided. The doctor ordered WBC lab to check for continuing elevated
481370 - results, to check the lab on 140814 1530. ref SDS 34 PS6G
481372 - ..
481373 - After the meeting, the line was long for a lab, so will get the blood
481374 - draw after returning from meeting with Doctor Tang at Podiatry in San
481375 - Francisco VA Medical Center.
481377 - ..
481378 - Doctor Sandhu was not aware of recent labs at San Francisco VA Medical
481379 - Center, listed in the most recent lab on 140814 1530. ref SDS 34 W25L
481380 - He seemed to indicate that VA Clinic in Martinez is on a different
481381 - server (Sacramento), so the doctor can't see results on the server for
481382 - the VA Medical Center in San Francisco, where labs have been done the
481383 - past year.
481385 - ..
481386 - Doctor Sandhu said he cannot make referral for EPC and CTA tests,
481387 - requested in the letter on 140814 2227, ref SDS 35 K04L, outside the
481388 - VA, as far as he knows.
481390 - ..
481391 - Doctor Sandhu did not discuss issue of low blood pressure presented in
481392 - the letter on 140814 2227. ref SDS 35 K13P
481393 -
481394 -
481395 -
4814 -
SUBJECTS
Default Null Subject Account for Blank Record
4903 -
490401 - ..
490402 - Medical Chart Progress Notes Meeting 131121 VA SF Medical Center
490403 -
490404 - Follow up ref SDS 25 LF4L, ref SDS 19 0001,.
490406 - ..
490407 - VA website is at...
490408 -
490409 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
490411 - ..
490412 - Customer....
490417 - ..
490418 - [On 140823 1049 VA Interent medical chart does not display
490419 - Progress Notes after 140804, including the meeting today on
490420 - 140819. ref SDS 37 098A
490422 - ..
490423 - Following was posted to VA Internet Medical Chart system and
490424 - downloaded on 140826....
490426 - ..
490427 - VA file from CD with Progress Notes for meeting on 140805 are stored
490428 - at...
490430 - ..
490431 - F:\05\00003\SM\CC\AGMJ\20140819-082839\WELCH_0144_8-19-14.txt
490433 - ..
490434 - F:\05\00441\CG\GG\HMC\20140819-082839\WELCH_0144_8-19-14.txt
490436 - ..
490437 - F:\05\00441\SM\BGMC\20140819-082839\WELCH_0144_8-19-14.txt
490438 -
490439 -
490440 - 1. LOCAL TITLE: Primary Care Scheduled Visit 60297
490441 - STANDARD TITLE: PRIMARY CARE NOTE
490442 - DATE OF NOTE: AUG 19, 2014@08:28:39
490443 - ENTRY DATE: AUG 19, 2014@08:28:39
490444 - AUTHOR: SANDHU, HARKESH S
490445 - EXP COSIGNER:
490446 - URGENCY:
490447 - STATUS: COMPLETED
490449 - ..
490450 - 2. 69 yo MALE with medical problems as listed in problem list came
490451 - in for f/u. pt has been in touch with most issues with a group
490452 - email. Pt has not hiked for two days due to his blister on the
490453 - left big toe. He has gained some weight just due to that.
490455 - ..
490456 - Patient reported in letter submitted on 140814, with agenda for this
490457 - meeting with Primary Care that weight gain caused by inability to hike
490458 - past 6 weeks due to metatarsalgia. ref SDS 35 K098
490460 - ..
490461 - Primary Care Progress Notes continue...
490462 -
490463 - 3. pt is planning to go hikking today and he hikes up to 11 miles.
490465 - ..
490466 - Patient reported in letter submitted on 140814, that taking ibuprofen
490467 - prescribed by Doctor Tang in Podiatry, VA SFMC on 140805, reduced
490468 - painful metatarsalgia enough to enable doing 3 14.2 mile hikes and 2
490469 - 11 miles hikes, beginning on 140805. ref SDS 35 K08W
490471 - ..
490472 - Primary Care Progress Notes continue...
490473 -
490474 - 4. Pt has a lesion over the nose which has not been healed for
490475 - over 6 montsh. pt will need derm eval.
490477 - ..
490478 - This aligns with discussion during the meeting today, per above,
490479 - ref SDS 0 EX7I, and with the letter submitted on 140814 2227.
490480 - ref SDS 35 K052
490482 - ..
490483 - Primary Care Progress Notes continue...
490484 -
490485 - 5. He had his egd and findings as in note and his PPi dose was
490486 - incresaed. No f/c/n/v/d/ chest pain/tightness. Pt states he
490487 - is having some swallowing issues and nausea problem and will
490488 - like to see if Dr Lee can check to see early appt.
490490 - ..
490491 - This aligns with discussion during the meeting today, per above,
490492 - ref SDS 0 TX8K, and with the letter submitted on 140814 2227.
490493 - ref SDS 35 K059
490494 -
490495 - [...below on 140819 0800 Progress Notes cite GERD Dysphagia
490496 - (difficulty swallowing) issue again requiring referral to
490497 - EGD. ref SDS 0 OD4Q
490499 - ..
490500 - [...below on 140819 0800 End of Progress Notes seem to
490501 - indicate Doctor Lee has not responded to notice.
490502 - ref SDS 0 VZ5K
490504 - ..
490505 - [On 141014 0943 Kathy visited EGD Clinic at VA Medical
490506 - Center in Sacramento and talked to Lapria, who advised that
490507 - on 141001, the VA responded to the letter on 140810, saying
490508 - EGD dilation is scheduled on 141121 1500 to implement order
490509 - for 6 months after prior procedure on 140509, which would
490510 - be on 141109. ref SDS 38 NU8L
490512 - ..
490513 - Primary Care Progress Notes continue...
490514 -
490515 - 6. Computerized Problem List is the source for the following:
490516 -
490517 - 1. Dizziness * (ICD-9-CM 780.4) 09/06/12 EGAN,JAMES
490518 - 2. Paresthesia * (ICD-9-CM 782.0) 09/06/12 EGAN,JAMES
490519 - 3. Vitamin D Deficiency 08/03/11 SANDHU,HARKESH
490520 - 4. Postsurgical Aortocoronary Bypass Status 03/09/11 EGAN,JAMES
490521 - (ICD-9-CM V45.81)
490522 - 5. Esophageal Stricture 03/05/10 LEE,RANDALL E
490523 - 6. Screening for Malignant Neoplasms of colon 11/15/11 LEE,RANDALL E
490524 - (ICD-9-CM V76.51)
490525 - 2010 colonoscopy: no polyp. Next screen 2020
490526 - 7. Coronary Atherosclerosis (unspecified type 02/02/10 LEE,RANDALL E
490527 - vessel, native or graft) (ICD-9-CM 41
490528 - 8. Coronary Artery Bypass using Venous and 01/04/10 SANDHU,HARKESH
490529 - Arterial Grafts (Single Vein Graft), Onset
490530 - 10/00/09
490531 - done at vasf
490532 - 9. Surgical Thoracoscopy with Esophagomyotomy 01/04/10 SANDHU,HARKESH
490533 - (Heller Type), Onset 12/16/09
490534 - at vasf
490535 - 10. Hyperlipidemia * (ICD-9-CM 272.4) 10/02/09 EGAN,JAMES
490536 - 11. Inflamed Seborrheic Keratosis (ICD-9-CM 03/12/07 LIN,BERTHA
490537 - 702.11)
490538 - 12. Rosacea * (ICD-9-CM 695.3) 03/12/07 LIN,BERTHA
490539 - 13. Dermatitis * (ICD-9-CM 692.9) 03/12/07 LIN,BERTHA
490540 - 14. Tinea Unguium * (ICD-9-CM 110.1) 03/12/07 LIN,BERTHA
490541 - 15. Tinea * (ICD-9-CM 110.9) 03/12/07 LIN,BERTHA
490542 - 16. Rosacea conjunctivitis (ICD-9-CM 372.31) 03/02/07 MARGULIES,LINDA
490543 - 17. Rosacea * (ICD-9-CM 695.3) 03/02/07 MARGULIES,LINDA
490544 - 18. Blepharitis NOS 02/21/07 MARGULIES,LINDA
490545 - 19. Achalasia * (ICD-9-CM 530.0) 12/22/05 SANDHU,HARKESH
490546 - 20. Abn. LFT's 08/16/05 SANDHU,HARKESH
490547 - 21. Obesity 06/29/05 SANDHU,HARKESH
490548 - 22. Rosacea 06/29/05 SANDHU,HARKESH
490549 - 23. Tinea Unguium 06/29/05 SANDHU,HARKESH
490551 - ..
490552 - Computerized Problem List does not show "Metatrsalgia" cited in Doctor
490553 - Alba's referral letter received in the record on 140805, 140805 1030,
490554 - ref SDS 31 AU9H, and subsequently diagnosed by Doctor Tang in Podiatry
490555 - Department at VA Medical Center in San Francisco also on 140805 1030.
490556 - ref SDS 31 UD5K
490558 - ..
490559 - Primary Care Progress Notes continue...
490560 -
490561 - 7. Active Outpatient Medications (excluding Supplies):
490562 -
490563 - 1. OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH ACTIVE
490564 - TWICE A DAY -15 MINUTES BEFORE MEALS FOR ACID
490565 - REFLUX
490567 - ..
490568 - For some reason, Primary Care does not list Atorvastatin 4-week trial
490569 - prescribed by VA SFMC on 131121 0930. ref SDS 23 6H6K Atorvastatin 40
490570 - MG was started on 131121, shown in case study on 120101 0900.
490571 - ref SDS 6 RN3F
490573 - ..
490574 - As well, Ezetimibe 10 mg and Atorvastatin 10 mg was started on 131230,
490575 - ref SDS 27 5N3O, further shown in case study on 120101 0900.
490576 - ref SDS 6 6A6H
490578 - ..
490579 - Primary Care Progress Notes continue...
490580 -
490581 - 8. PE: [Physical Examination]
490582 -
490583 - 1. Most recent vitals:
490584 -
490585 - Temperature: 96.7 F [35.9 C] (08/19/2014 08:01)
490586 - Pulse: 63 (08/19/2014 08:01)
490587 - Respirations: 18 (08/19/2014 08:01)
490588 - B/P: 125/69 (08/19/2014 08:01)
490589 - Height: 66 in [167.6 cm] (05/09/2014 08:39)
490590 - Weight: 187.8 lb [85.4 kg] (08/19/2014 08:01)
490591 - BMI: 30.4
490592 - Pain: 0 (08/19/2014 08:01)
490593 - HEENT: nc, at, perrl,eomi,thgere is a small skin lesion
490594 - pinhead size near bridge of nose and a small lesion lower
490595 - down.
490597 - ..
490598 - 2. NECK: no lymph nodes,trachea central,no bruit.
490600 - ..
490601 - 3. LUNGS: clear to auscultation and percussion
490603 - ..
490604 - 4. CARDIAC: nl s1s2 no murmur,
490606 - ..
490607 - 5. ABDOMEN: Soft, nontender, BS active, no HSM, no masses
490609 - ..
490610 - 6. EXT: No cyanosis,clubbing or edema.
490612 - ..
490613 - 7. NEURO: alert and oriented x3 , cn 2 -12 intact.
490615 - ..
490616 - For some reason at this point Primary Care Progress Notes incorporate
490617 - section of Progress Notes from meeting with EGD Department at VA
490618 - Sacramento Medical Center on 140509. 140509 0900, ref SDS 28 P396
490620 - ..
490621 - Primary Care Progress Notes continue...
490622 -
490623 - 8. EGD FINDINGS:
490624 -
490625 - 1. Previous area of esophageal stricture again identified
490626 - at the 39 cm distance. The best estimation of starting
490627 - diameter is greater than 16.5 mm but less than 18mm.
490629 - ..
490630 - 2. Shallow ulceration immediately after the GE junction,
490631 - which was iopsied, labeled specimen A.
490633 - ..
490634 - 3. Gastric fundus surgically altered consistent with known
490635 - history of fundoplication.
490637 - ..
490638 - 4. Hiatal hernia identified.
490640 - ..
490641 - 5. Normal pylorus.
490643 - ..
490644 - 6. Normal duodenum to D2.
490646 - ..
490647 - 9. IMPRESSION:
490648 -
490649 - 1. Gastroesophageal reflux stricture with minor recurrence
490650 - since the prior examination and dilation in November
490651 - 2013. The appearance of the ulceration suggests the
490652 - patient would benefit from an increased dose of proton
490653 - pump inhibitor therapy on a daily basis.
490655 - ..
490656 - 2. Appearance of hiatal hernia suggests the fundoplication
490657 - appears to be loosening.
490659 - ..
490660 - 10. RECOMMENDATIONS:
490661 -
490662 - 1. Increase omeprazole to 20 mg twice daily and maintain.
490663 - 2. Repeat EGD and dilation in approximately 6 months.
490664 - 3. Await the pathology results.
490666 - ..
490667 - This concludes portion of Progress Notes from EGD meeting on 140509.
490669 - ..
490670 - Primary Care Progress Notes continue...
490671 -
490672 - 9. LABS:
490673 -
490674 - Collection DT Spec GLUCOSE BUN CREAT NA K CL CO2
490675 - 08/14/2014 15:28PLASMA 98 15 1.03 144 4.3 108 H 29
490676 - 02/03/2014 09:52PLASMA 103 17 0.82 140 5.4 H 103 30
490678 - ..
490679 - Collection DT Spec ALT AST ALK PHO ALBUMIN T. BIL
490680 - 08/14/2014 15:28 PLASM 21 25 85 4.3 2.5 H
490681 - 02/03/2014 09:52 PLASM 21 23 85 4.1 2.1 H
490683 - ..
490684 - Collection DT Spec WBC HGB HCT MCV MCHC PLT
490685 - 08/14/2014 15:28 BLOOD 12.8 H 16.2 48.3 88.7 33.6 295
490686 - 05/29/2013 08:18 BLOOD 7.4 15.0 46.2 90.7 32.5 279
490688 - ..
490689 - SCLU - TSH
490690 - Collection DT Spec Tsh
490691 - 08/14/2014 15:29 SERUM 2.61
490692 - 10/15/2013 08:25 SERUM 2.62
490694 - ..
490695 - Collection DT Spec CHOL TRIGLYC HDL LDL-CHO
490696 - 08/14/2014 15:28 PLASM 161 72 55 92
490697 - 02/03/2014 09:52 PLASM 160 47 58 93
490699 - ..
490700 - 10. ASSESSMENT AND PLAN:
490701 -
490702 - 1. Parasthesia/ Metatarsalgia : He has not had much difference.
490704 - ..
490705 - Including metatarsalgia with parasthesia and saying "not much
490706 - difference" appears conflicting with notice in letter on 140814,
490707 - reporting metatarsalgia prevented hiking past 6 weeks, and is now
490708 - being treated by Podiatry beginning on 140805, ref SDS 35 F06N, since
490709 - podiatry issue was not reported in Progress Notes for prior meeting in
490710 - Primary Care on 131209 0800. ref SDS 25 T130
490712 - ..
490713 - Primary Care Progress Notes continue...
490714 -
490715 - 2. HTN/CAD : Cont current meds. care per cardiology.
490717 - ..
490718 - 3. Hyperlip/obesity : care asper VASF clinic. Pt is on atorvastatin from VASF.
490720 - ..
490721 - Current treatment with Atorvastatin 10 mg and Ezetimibe 10 mg
490722 - prescribed by Doctor Alba at VA SFMC on 131219 0930, ref SDS 26 6H6K,
490723 - and per comment on Active Medications above. ref SDS 0 BS6I
490725 - ..
490726 - As well, patient being treated in Podiatry to resume hiking that
490727 - resolves hyperlipademia and obesity, explained during meeting with
490728 - Doctor Tang on 140805 1030. ref SDS 31 1E56
490730 - ..
490731 - Primary Care Progress Notes continue...
490732 -
490733 - 4. Heel pain / planter fascitis ; doing ok .
490735 - ..
490736 - There is no evident record of "heal pain" nor discussion of "planter
490737 - fascitis" in the record of patient history.
490739 - ..
490740 - Doctor Sandhu correctly cites medical feet problem of "metatarsalgia"
490741 - Progress Notes under "Assessment and Plan" para 1, though incorrectly
490742 - pairing this with "Parathesia," and stating "not much difference."
490743 - above. ref SDS 0 T130
490745 - ..
490746 - Primary Care was notified in a letter on 140814, that cited a letter
490747 - to Podiatry on 140806, confirming meeting to recover from severe
490748 - symptoms of metatarsalgia that prevented hiking for 6 weeks.
490749 -
490751 - ..
490752 - Primary Care Progress Notes continue...
490753 -
490754 - 5. GERD / Dysphagia/ Nausea: Will bring to Dr Lee attention
490755 - per pt request.
490757 - ..
490758 - Plan to notify Doctor Lee that patient needs timely care to resolve
490759 - rising swallowing difficulties, aligns with Notes above. ref SDS 0
490760 - 4K5F
490761 -
490762 - [...below on 140819 0800 Progress Notes show Receipt
490763 - Acknowledged By: AWAITING SIGNATURE LEE,RANDALL E,
490764 - indicating glitch in VA computer system. ref SDS 0 VZ5K
490766 - ..
490767 - [On 141014 0943 Kathy visited EGD Clinic at VA Medical
490768 - Center in Sacramento and talked to Lapria, who advised that
490769 - on 141001, the VA responded to the letter on 140810, saying
490770 - EGD dilation is scheduled on 141121 1500 to implement order
490771 - for 6 months after prior procedure on 140509, which would
490772 - be on 141109. ref SDS 38 NU8L
490774 - ..
490775 - Primary Care Progress Notes continue...
490776 -
490777 - 6. Skin lesion nose : Derm referral.
490779 - ..
490780 - Referral to Dermatology to care for nose sore aligns with Notes above.
490781 - ref SDS 0 5X4J
490783 - ..
490784 - Primary Care Progress Notes continue...
490785 -
490786 - 7. Leukocytosis : Will recheck cbc today.
490788 - ..
490789 - The doctor ordered CBC to recheck WBC 12.8 elevated likely due to
490790 - blister on left foot, and to see if recovery has occurred that lowers
490791 - WBC back into range.
490793 - ..
490794 - Primary Care Progress Notes continue...
490795 -
490796 - 11. Rtc in 6 months.
490798 - ..
490799 - 12. Clinical Reminders:
490800 -
490801 - 1. Medication Reconciliation:
490802 -
490803 - No Changes To Medications:
490804 -
490805 - 1. The patient's current CPRS Medication List was
490806 - reviewed with Patient/Caregiver, and was found to
490807 - be correct and up to date.
490808 -
490809 - -no meds added
490810 - -no meds discontinued
490811 - -no meds changed
490812 - -no discrepancies noted
490814 - ..
490815 - See comment on Active Outpatient Medications, above. ref SDS 0 BS6I
490817 - ..
490818 - Primary Care Progress Notes continue...
490819 -
490820 - 2. Patient/Caregiver has a reconciled medication
490821 - list.
490823 - ..
490824 - 3. The importance of managing personal medication
490825 - information was discussed w/ Patient/Caregiver:
490827 - ..
490828 - Patient history shows daily medication management, see case study
490829 - begining, 120101 0900, ref SDS 6 QJ5I
490831 - ..
490832 - Medication management past 6 months since prior meeting in Primary
490833 - Care on 131209, is also shown in the study. ref SDS 6 VQ4M
490835 - ..
490836 - Primary Care Progress Notes continue...
490837 -
490838 - -carry medication list at all times, in the event
490839 - of emergency
490841 - ..
490842 - -update medication list when meds are added,
490843 - stopped, or changed
490845 - ..
490846 - -give a list to his/her primary care physician at
490847 - every visit and bring medication bottles if
490848 - possible
490850 - ..
490851 - 2. Assess Statin Use - Lipids (CVD/DM):
490852 -
490853 - The patient is currently on a moderate or high dose
490854 - statin.
490856 - ..
490857 - Patient history in case study shows patient taking daily Atorvastatin
490858 - 10 mg and Ezetimibe 10 mg, discussed above. ref SDS 0 OW9K
490860 - ..
490861 - See as well VA Preventive Health Notes, below. ref SDS 0 N29H
490862 -
490863 -
490868 - ..
490869 - Receipt Acknowledged By:
490870 - * AWAITING SIGNATURE * LEE,RANDALL E
490872 - ..
490873 - Status "awaiting signature" to acknowledge "receipt" of notice on
490874 - rising swallowing problems for expedited EGD dilation procedure, shown
490875 - in Progress Notes "Assessment and Plan," above, ref SDS 0 OD4Q, aligns
490876 - with lack of response to notice submitted through VA online computer
490877 - message system on 140810 1839. ref SDS 32 W83K May reflect overworked
490878 - computer system that delayed delivery of Omeprazole prescription
490879 - refill reported on 140718 1017. ref SDS 30 U88L Similarly, VA
490880 - computer system reported overwhelmed by increased transaction volume
490881 - due to rising VA enrollment, shown in the record on On 140812 1400.
490882 - ref SDS 33 A163
490883 -
490884 - [On 141014 0943 Kathy visited EGD Clinic at VA Medical
490885 - Center in Sacramento and talked to Lapria, who advised that
490886 - on 141001, the VA responded to the letter on 140810, saying
490887 - EGD dilation is scheduled on 141121 1500 to implement order
490888 - for 6 months after prior procedure on 140509, which would
490889 - be on 141109. ref SDS 38 NU8L
490890 -
490891 -
490892 -
490893 -
490894 -
490895 -
4909 -
SUBJECTS
Default Null Subject Account for Blank Record
5003 -
500401 - ..
500402 - Preventive Health Review with Nurse
500403 -
500404 -
500405 - 1. LOCAL TITLE: PC Preventive Health 60498
500406 - STANDARD TITLE: PREVENTIVE MEDICINE RISK ASSESSMENT SCREENING NO
500407 - DATE OF NOTE: AUG 19, 2014@08:03
500408 - ENTRY DATE: AUG 19, 2014@08:03:56
500409 - AUTHOR: MARTINEZ,GLORIA
500410 - EXP COSIGNER:
500411 - URGENCY:
500412 - STATUS: COMPLETED
500414 - ..
500415 - 2. Clinical Reminders:
500417 - ..
500418 - 3. LVN Medication Inventory:
500419 - LVN MEDICATION INVENTORY
500421 - ..
500422 - 4. Allergies:
500424 - ..
500425 - Patient has answered NKA
500427 - ..
500428 - 5. Active and Recently Expired Outpatient Medications (excluding
500429 - Supplies):
500431 - ..
500432 - Active Outpatient Medications Status
500433 - ======================================================================
500434 -
500435 - 1) OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH ACTIVE
500436 - TWICE A DAY -15 MINUTES BEFORE MEALS FOR ACID
500437 - REFLUX.
500439 - ..
500440 - Active Medications from Remote Data
500442 - ..
500443 - 2) EZETIMIBE 10MG TAB
500444 - Sig: TAKE ONE TABLET ORALLY EVERY DAY
500445 - Quantity: 90 Days Supply: 90
500446 - 1 refills remaining until 05/20/15
500447 - Last filled 05/21/14 at SAN FRANCISCO VAMC (Active)
500449 - ..
500450 - 3) ATORVASTATIN CA 20MG TAB
500451 - Sig: TAKE ONE-HALF TABLET ORALLY AT BEDTIME FOR CHOLESTEROL
500452 - Quantity: 45 Days Supply: 90
500453 - 3 refills remaining until 05/20/15
500454 - Last filled 06/20/14 at SAN FRANCISCO VAMC (Active)
500455 -
500456 -
500458 - ..
500459 - 6. Patient Education:
500460 -
500461 - Hand Hygiene
500463 - ..
500464 - 7. Vitals:
500465 -
500466 - 1. Most recent VS: Wt. 187.8 lb [85.4 kg] (08/19/2014 08:01)
500467 - BP 125/69 (08/19/2014 08:01)
500468 - HR 63 (08/19/2014 08:01)
500469 - Temp 96.7 F [35.9 C] (08/19/2014 08:01)
500470 - BMI 30.4
500472 - ..
500473 - 2. BMI based on most recent Ht/Wt. 30.4
500474 -
500476 - ..
500477 - 8. Barriers to Education Not Recorded:
500478 -
500479 - The patient has no noted or self-perceived barriers to learning.
500481 - ..
500482 - The patient is ready to learn and is receptive.
500484 - ..
500485 - 9. Nutrition Screening:
500486 -
500487 - The patient notes no significant weight change.
500489 - ..
500490 - This conflicts with notice to VA that weight has changed significantly
500491 - from 163 to 187 past 6 weeks due to metatarsalgia causing inability to
500492 - hike, shown in letter on 140814 2227. ref SDS 35 K098
500494 - ..
500495 - Primary Care Progress Notes cite weight gain, per above. ref SDS 0
500496 - OK6F
500498 - ..
500499 - VA Notes PC Preventive Health 60498 continue...
500500 -
500501 - Most recent measurements:
500503 - ..
500504 - Measurement DT WEIGHT LB(KG)[BMI]
500505 - 08/19/2014 08:01 187.8(85.18)[30*]
500506 - 05/09/2014 08:39 179(81.19)[29*]
500507 - 04/30/2014 09:01 177.5(80.51)[29*]
500508 - 12/09/2013 07:58 182(82.55)[29*]
500510 - ..
500511 - Ht. 66 in [167.6 cm] (05/09/2014 08:39)
500512 - BMI 30.4
500514 - ..
500515 - 10. Advance Directive Screening:
500516 -
500517 - MEDICAL FORMS SCREENING:
500518 -
500519 - 1. Informed patient that it is up to you to decide if you want
500520 - an advance directive. Your decision will not affect your
500521 - access to care.
500523 - ..
500524 - 2. Informed Veteran that it is your responsibility to provide
500525 - a copy of your Advance Directive if you have one & if
500526 - unable to provide a copy of your Advance Directive, you may
500527 - complete a new Advance Directive. If we do not have a
500528 - signed copy of your Advance Directive, there is no way for
500529 - us to know your wishes. You will be treated as if you
500530 - don't have one until you either complete a new Advance
500531 - Directive or provide us with a copy of one you may already
500532 - have.
500534 - ..
500535 - 3. Do you have an Advance Directive (DPAHC or Living Will) or
500536 - a Mental Health Advance Directive on file with us or a copy
500537 - to give to us today?
500539 - ..
500540 - 4. The patient indicates that they do not have an Advance
500541 - Directive.
500543 - ..
500544 - During the meeting today, advised Gloria that Advance Directive was
500545 - filed with VA Medical Center in San Francisco for CABG +4 surgery
500546 - on 091023 0445. ref SDS 3 WO5Y
500548 - ..
500549 - VA Notes PC Preventive Health 60498 continue...
500550 -
500551 - 5. Veteran does not wish to discuss further with a health care
500552 - provider at this time.
500554 - ..
500555 - 11. Homelessness Screening:
500556 -
500557 - 1. In the past 2 months, have you been living in stable
500558 - housing that you own, rent, or stay in as part of a
500559 - household? Yes - Living in stable housing.
500560 -
500561 - 2. Are you worried or concerned that in the next 2 months you may
500562 - NOT have stable housing that you own, rent, or stay in as part
500563 - of a household?
500565 - ..
500566 - 3. No - Not worried about housing near future
500568 - ..
500569 - 12. Screen for Depression:
500570 -
500571 - PHQ-2
500573 - ..
500574 - A PHQ-2 screen was performed. The score was 0 which is a negative
500575 - screen for depression.
500576 -
500577 - 1. Little interest or pleasure in doing things
500578 -
500579 - Not at all
500581 - ..
500582 - 2. Feeling down, depressed, or hopeless
500583 -
500584 - Not at all
500586 - ..
500587 - This is somewhat conflicting with discussion during the meeting.
500589 - ..
500590 - Patient is depressed about....
500591 -
500592 - 1. Cannot do pushups due to sore left elbow
500593 - 2. Cannot hike due to metatarsalgia
500594 - 3. Metatarsalgia solution delayed getting shoes and orthotics
500595 - 4. Weight gain due to cannot hike
500596 - 5. Lipids worsen due to cannot hike
500597 - 6. Difficulty testing regression atherosclerosis with EPC and CTA
500598 - 7. Swallowing problems due to triamcinolone not injected LESV on 140509
500599 - 8. Difficulty advancing dilation resolve swallowing problems
500600 - 9. Cannot resolve delays Omeprazole prescription refill
500602 - ..
500603 - Patient is hopeful working with great VA team providing outstanding
500604 - care shown by CABG +4 beginning on 091021 0716. ref SDS 2 01F9, and by
500605 - treatment for achalasia discussed with Doctor Lee on 130416 1100,
500606 - ref SDS 17 IN5N, and citing radiology findings of substantial
500607 - recovery. ref SDS 17 XT8M
500608 -
500609 - /e s/ Gloria Martinez, LVN
500610 - LV N, Primary Care
500611 - Si gned: 08/19/2014 08:05
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