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 89 0000. ref SDS 74 0000.
600502 -
600503 -
600504 -
600506 - ..
6006 -
6007 -
6008 - Background
6009 -
6010 -
601001 - Lab on 131015, showing cholesterol remained high, 131015 0724,
601002 - ref SDS 48 BE6O, conflict with increased exercise and weight loss,
601003 - discussed in the letter to the medical team yesterday on 131016 1632.
601004 - ref SDS 49 IW57
601006 - ..
601007 - On 131017 1000 VA medical chart Progress Notes assessment report
601008 - patient status CAD stable, asymptomatic. hyperlipidemia not
601009 - controlled. ref SDS 50 T24N
601011 - ..
601012 - On 131017 1000 Doctor Egan proposed referring patient for clinical
601013 - trial to reduce cholesterol with new "targeted" drugs. ref SDS 50 179N
601015 - ..
601016 - On 131017 1000 VA medical chart Progress Notes assessment report
601017 - patient status hyperlipidemia not controlled, ref SDS 50 PSXT; Doctor
601018 - Egan makes referral to SF VA Medical Center for consult on
601019 - participation clinical trials, ref SDS 50 EU9F, with experimental
601020 - agents such as AMGEN 145 and REGN 727 to resolve multiple statin
601021 - intolerance. ref SDS 50 CN4H
601023 - ..
601024 - On 131103 received letter from VA SF Medical Center scheduling meeting
601025 - on 131121 1000, to consider clinical trial for lowering cholesterol.
601026 - ref SDS 52 YT4N
601028 - ..
601029 - On 131112 New York Times published several articles reporting that the
601030 - day before on 131113, American Heart Association published new
601031 - guidelines for treating CAD patients that expand use of statin
601032 - medication regardless of cholesterol levels, ref SDS 53 0001, and
601033 - further raise the LDL 70 to LDL 190, as a target for cardiovascular
601034 - risk. ref SDS 53 CW6H
601036 - ..
601037 - On 131114 New York Times published several articles reporting that the
601038 - day before on 131113, American Heart Association published new
601039 - guidelines for treating CAD patients. ref SDS 54 SH6G
601041 - ..
601042 - On 131121 1604 meeting with Doctor Alba at San Francisco Medical
601043 - Center - prescribed Atorvastatin 20 mg 4-week trial and evaluate
601044 - adding Zetia 10 mg, schedule follow up on 131219 0930. ref SDS 55 6H6K
601046 - ..
601047 - On 131121 1604 in another record later today, VA prescription RX #
601048 - 5674471 for Atorvastatin 20 mg has been ordered. ref SDS 57 GH5M
601050 - ..
601051 - On 131125 0005 letter from Karen reports VA work plan to take statin
601052 - drug low dose Atorvastatin 10 mg for 4 weeks, then add Zetia 10 mg in
601053 - clinical trial for lowering cholesterol. ref SDS 59 V154
601055 - ..
601056 - On 131125 0005 research seems to indicate this clinical trial of low
601057 - dose Atorvastatin 10 mg with Zetia 10 mg has lowered cholesterol LDL
601058 - 70.
601060 - ..
601061 - On 131205 1448 received new prescription for Atorvastatin 20 mg,
601062 - ordered by Doctor Alba today for 4-week trial to assess side effects
601063 - for adding 2nd drug, Zetia 10 mg to lower LDL 249. ref SDS 60 GH5M
601065 - ..
601066 - On 131216 0028 letter to Doctor Alba submit agenda for meeting at VA
601067 - SFMC on 131219. ref SDS 61 HY6O
601069 - ..
601070 - On 131219 0930 meeting Doctor Alba at San Francisco VA Medical Center
601071 - ordered Ezetimibe 10 mg prescription for adding to Atorvastatin, and
601072 - ordered blood test to evaluate changes in lipid profile. 131219 0930,
601073 - ref SDS 62 NJ6G
601075 - ..
601076 - On 131230 1450, received Ezetimibe in US mail, ref SDS 63 5N3O,
601077 - ordered by Doctor Alba on 131219, 131219 0930, ref SDS 62 6H6K; begin
601078 - trial to manage cholesterol with Atorvastatin 10 mg and Ezetimibe 10
601079 - mg, planned during meeting at VA on 131121 0930. ref SDS 55 6H6K
601081 - ..
601082 - On 140114 0845 letter to Diana request Progress Notes meeting 131219,
601083 - ref SDS 65 HY6O, and ask about expanding scope pending lab to include
601084 - LDL-P. ref SDS 65 2140
601086 - ..
601087 - On 140115 1842 letter Diana will look for Progress Notes meeting
601088 - 131219, ref SDS 66 HY6O; investigating prospects for ordering lab test
601089 - LDL-P, ref SDS 66 CE80; VA claims patient cholesterol and LDL are above
601090 - target. ref SDS 66 CE91 VA further claims testing LDL-P not effective
601091 - in this case because LDL-C is not optimal. ref SDS 66 FF4H
601093 - ..
601094 - On 140116 0814 letter thanks Doctor Alba for investigating to find
601095 - Progress Notes for meeting at VA on 131219. ref SDS 67 HY6O Cite
601096 - research indicating patient with discordant LDL-C high and LDL-P low,
601097 - shown in patient lab on 131015, constitutes least risk for
601098 - arteriolosclerosis disorder, CVD, myocardial infarction. ref SDS 67 735Y
601100 - ..
601101 - On 140128 1327 letter asks again about Progress Notes meeting 131219,
601102 - ref SDS 68 HY6O; report hiking 11 miles per day continued, weight hit
601103 - 165, ref SDS 68 TZ8U; ask where to get lab at VA Martinez, in San
601104 - Francisco, or at UCSF. ref SDS 68 TZ96 No side effects from
601105 - Atorvastatin and Ezetimibe. ref SDS 68 TZ99
601107 - ..
601108 - On 140131 0815 have not received instructions from VA on getting lab
601109 - to test LDL-P, so ordered test. ref SDS 69 OO5G lab blood draw at
601110 - Labcorp in Walnut Creek on Ygnacio Valley Road. ref SDS 69 NT6T
601112 - ..
601113 - On 140201 1159 obtained blood draw for Lipid NMR test at Labcorp on
601114 - Health Testing Centers order # 27716, ref SDS 70 KQ4L, showing
601115 - "concordance" LDL-P 861, LDL-C 81, HDL 61, TG 68, LDL (pattern A) size
601116 - = large buoyant protective. ref SDS 70 IM9N
601118 - ..
601119 - On 140203 1147 VA blood draw at Martinez clinic to cross check Labcorp
601120 - blood test. 140203 1147, ref SDS 71 KK9M, showing LDL-C 93, HDL 58, TG
601121 - 47, ref SDS 71 IM9N, indicating "concordance" LDL-P 626, LDL (pattern
601122 - A) size = large buoyant protective. ref SDS 71 QV5G
601124 - ..
601125 - On 140204 1236 letter from VA today, notifies that Progress Notes for
601126 - meeting on 131219, have been posted and are available for customer to
601127 - receive from ROI department. ref SDS 72 HY6O Cause for 6-weeks delay
601128 - issuing Progress Notes not clear in the record. ref SDS 72 V44F VA
601129 - Progress Notes for meeting on 131219, are comprehensive and helpful.
601130 - ref SDS 72 MR3G Progress Notes have many minor grammatical errors
601131 - likely due to limited time, ref SDS 72 MZ5H, VA does not support NMR
601132 - lipid tests to determine LDL-P and discordance with LDL-C; patient can
601133 - obtain test from another lab. ref SDS 72 CE80 VA letter today
601134 - maintains discordance with low LDL-P and high LDL-C is "unhealthy" -
601135 - submits no evidence from medical literature supporting this
601136 - proposition, nor to address literature submitted to the VA stating
601137 - discordance is the healthiest condition for CVD patients. ref SDS 72
601138 - 6U4L VA concurs that lowering weight toward BMI standards aids
601139 - resolving hyperlipidemia. ref SDS 72 8N9H VA maintains lifestyle
601140 - through exercise and diet to control weight and hyperlipidemia require
601141 - support taking statin medications, e.g., Atorvastatin and Ezetimibe.
601142 - ref SDS 72 GT5F VA letter today says patient mis-reads literature on
601143 - discordance between LDL-P and LDL-C, and proposes discussions to
601144 - clarify this matter during meeting scheduled on 140213. ref SDS 72 HU5M
601145 - VA prefers patient get labs drawn at San Francisco VA Medical Center.
601146 - ref SDS 72 PT3M
601148 - ..
601149 - On 140211 0133 letter submits agenda to VA for meeting scheduled on
601150 - 140213. ref SDS 73 HY6O Progress Notes on 131219 received from VA on
601151 - 140204 1236. ref SDS 72 HY6O, stating LDL-P provides stronger
601152 - association with CVD risk, ref SDS 62 GO35, and VA letter saying
601153 - patient can support the team with NMR lab, reported on 140204 1236.
601154 - ref SDS 72 CE80, was implemented on February 1 using Labcorp. VA
601155 - request to have lab at San Francisco reported on 140204 1236.
601156 - ref SDS 72 PT3M, was received the day after lab was drawn at Martinez.
601157 - Will do VA labs in San Francisco for next cycle. ref SDS 73 TU68
601159 - ..
601160 - On 140211 0133 letter notifies VA consolidated patient history shows
601161 - strong alignment, ref SDS 73 TV31, between NMR test on 140201, and VA
601162 - lipid panel 2 days later on 140203. ref SDS 71 IM9N Low LDL-P 861
601163 - concordant with low LDL-C 81 in Labcorp NMR report on 140201. TG 47
601164 - and HDL 58 in VA lab 2 days later on 140203 1147, ref SDS 71 5C7M,
601165 - aligns with Labcorp results. ref SDS 73 TV3M Labcorp further shows
601166 - LDL size 21.3 is "pattern A", indicating large, buoyant LDL particles
601167 - "protect" against CVD. While research indicates discordance with
601168 - LDL-P low and LDL-C high is the healthiest cardiovascular condition
601169 - shown on 131125 0005, ref SDS 59 FI3G, and submitted to the VA in a
601170 - letter on 140116 0814, ref SDS 67 H29T; and previously cited in a
601171 - prior letter on 140114 0845, ref SDS 65 2140, patient healthy and very
601172 - grateful for outstanding care by entire VA team. ref SDS 73 TV3M
601174 - ..
601175 - On 140211 0133 letter notifies VA lab on 140203 improving prior lab on
601176 - 131015, ref SDS 73 TV40, resulted from Atorvastatin 40 mg - 4 weeks
601177 - beginning on 131121, shown in case study on 120101 0900, ref SDS 21
601178 - RN3F, then Atorvastatin 10 mg and Ezetimibe 10 mg beginning on 131230,
601179 - also in case study, ref SDS 21 6A6H, making total for 8 weeks
601180 - Atorvastatin 1850 mg, Ezetimibe 340 mg; as well, hiking 933 miles,
601181 - weight loss to 165, low-carb diet, chia seeds, orange juice, as
601182 - further set out in the record for the lab at the VA on 140203.
601183 - ref SDS 71 I17G
601185 - ..
601186 - On 140211 0133 letter notifies VA lab on 140203 shows potassium (K 5.4)
601187 - is elevated again, ref SDS 73 TV5F, and T Bilirubin 2.1 further
601188 - increased again, while Labcorp shows these are stable. ref SDS 71 ZG5O
601190 - ..
601191 - On 140213 0830 meeting at VA Medical Center in San Francisco
601192 - ref SDS 74 195I, good progress lowering risks of CVD based on
601193 - concordant low LDL-P 861 with low LDL-C 81. shown by lab NMR lipid
601194 - panel. ref SDS 74 TB6J Medical team excellent results collaborating
601195 - doctor/patient partnership. ref SDS 74 1L7M Atorvastatin 40 mg
601196 - started 131121, and then changed to Atorvastatin 10 mg with Ezetimibe
601197 - 10 mg started 131230. ref SDS 74 IE7F No side effects taking
601198 - medication. ref SDS 74 333L Discordance between LDL-P and LDL-C
601199 - discussed. ref SDS 74 WM8J Continue medication, diet, exercise and
601200 - weight loss protocols, and test lipid panel again in 3 months on
601201 - 140519 0800. ref SDS 74 8X5O
601203 - ..
601204 - On 140213 0830 meeting at VA Medical Center in San Francisco request
601205 - test for regression of atherosclerosis plaque using coronary CTA to
601206 - evaluate CVD risk which 5 years earlier required surgery in 2009.
601207 - ref SDS 74 JZ4O
601209 - ..
601210 - On 140213 0830 Progress Notes for meeting at VA Medical Center in San
601211 - Francisco have numerous errors, e.g., failing to report hiking 933
601212 - miles that lowered Triglycerides and raised HDL to reduce CVD risk
601213 - through regression of atherosclerosis. ref SDS 74 O55H VA
601214 - representation that LDL "still not at goal" conflicts with the record,
601215 - and fails to present the "goal" and the authority that supports it.
601216 - ref SDS 74 WF5J VA representation that total cholesterol and LDL-C
601217 - are above target conflicts with the most recent lab showing both labs
601218 - are below target. ref SDS 74 5I7H
601220 - ..
601221 - On 140213 0830 Progress Notes for meeting at VA Medical Center in San
601222 - Francisco state LDL-P has stronger association with cardiovascular
601223 - risk than LDL-C. ref SDS 74 S35H Patient LDL-P 861 with Labcorp test
601224 - on 140201, is "optimal" - 150 points lower target of 1000 for minimal
601225 - CVD risk, shown in consolidated lab on 140203. ref SDS 71 BE6O VA
601226 - representation that patient LDL-C is not at optimal levels conflicts
601227 - with VA record of lab tests on 140203 1147, ref SDS 71 BE6O, and is
601228 - otherwise not supported by reference to recognized authority.
601229 - ref SDS 74 S35H
601231 - ..
601232 - On 140213 0830 Progress Notes for meeting at VA Medical Center in San
601233 - Francisco Plan of care prescribes continue physical activity and low
601234 - fat/low cholesterol diet. ref SDS 74 E34O
601236 - ..
601237 - On 140226 1332 letter to VA transmits notes of meeting on 140213.
601238 - ref SDS 75 HY6O Report cold symptoms side effects taking Atorvastatin
601239 - with Ezetimibe. ref SDS 75 JY8K Request coronary CTA radiology test
601240 - regression atherosclerosis. ref SDS 75 JR99 Request Progress Notes
601241 - meeting on 140213. ref SDS 75 JY4M
601243 - ..
601244 - On 140303 1644 letter to VA reports recovery from symptoms of cold,
601245 - which may indicate this was not caused by prescribed medication side
601246 - effects taking Atorvastatin and Ezetimibe. ref SDS 76 HY6O Letter
601247 - requests Progress Notes for meeting a few weeks ago at Medical Center
601248 - in San Francisco, and because Release of Information (ROI) department
601249 - at the VA Clinic in Martinez has been delayed issuing patient medical
601250 - records. ref SDS 76 E788
601252 - ..
601253 - On 140305 1117 letter to VA follows up asking about work plan in
601254 - Progress Notes doing CT and other testing to evaluate regression of
601255 - atherosclerosis, ref SDS 77 WY3X, since CABG x4 surgery on 091022
601256 - 0700. ref SDS 7 PQWU
601258 - ..
601259 - On 140307 1509 letter notifies VA that Ezetimibe and Atorvastatin
601260 - prescription refill not delivered, and so treatment is paused pending
601261 - delivery. 140307 1509, ref SDS 78 5N3O
601263 - ..
601264 - On 140307 1509 at 1730 VA letter reports plans to investigate to
601265 - resolve delayed delivery of prescription refill for Atorvastatin and
601266 - Ezetimibe. ref SDS 78 MS9N
601268 - ..
601269 - On 140308 0956 another letter asking VA to investigate delayed
601270 - delivery medication refills. ref SDS 79 II91
601272 - ..
601273 - On 140310 0939 another letter to VA requests assistance again
601274 - resolving delayed delivery medication refills for Atorvastatin and
601275 - Ezetimibe. ref SDS 80 LS88 On 140310 0939 at 1121 VA letter responds
601276 - to letter sent at 0939, and asks if medication refills have been
601277 - delivered for Atorvastatin and Ezetimibe. ref SDS 80 VP4J At 1156
601278 - notified VA have not received medication. ref SDS 80 345R
601280 - ..
601281 - On 140311 1730 received prescription refill for Atorvastatin and
601282 - Ezetimibe, delivered by neighbor because mailman delivered to the
601283 - wrong mailbox; treatment resumed. ref SDS 81 YS4O At 1903 notified VA
601284 - medication refill was received, so treatment resumed. ref SDS 81 KF5I
601286 - ..
601287 - On 140312 1720 letter to VA Medical Center in San Francisco submits
601288 - comments on Progress Notes for meeting on 140213. ref SDS 82 5N3O
601289 - Recommend corrections to avoid propagating errors forward when current
601290 - Progress Notes are used to expedite making Progress Notes for the next
601291 - meeting scheduled on 140519. ref SDS 82 IL83
601293 - ..
601294 - On 140312 1720 letter to VA Medical Center in San Francisco submits
601295 - question on goals for HDL and TG to lower LDL-P that has the strongest
601296 - association with CVD risk, ref SDS 82 IL4M, cited in VA Progress Notes
601297 - on 131219, ref SDS 62 GO35, and restated in Progress Notes for meeting
601298 - on 140213 0830. ref SDS 74 S35H
601300 - ..
601301 - On 140312 1720 letter to VA Medical Center in San Francisco requests
601302 - guidance in Progress Notes on goals for diet and exercise that yielded
601303 - dramatic rise in HDL 21% and reduction of TG 60%, given that research
601304 - indicates Atorvastatin and Ezetimibe have been found to increase HDL
601305 - 5%-9%, and lower TG 30%-40% [...reported on 131125 0005. ref SDS 59
601306 - PU6I...] - see AHA article Circulation published 030428...
601308 - ..
601309 - On 140312 1720 letter to VA Medical Center in San Francisco requests
601310 - testing for regression of atherosclerosis that lowers CVD risk based
601311 - on labs showing elevated HDL in combination with low TG, ref SDS 82
601312 - PSXX, discussed during the meeting on 140213 0830, ref SDS 74 JZ4O,
601313 - citing research on 131125 0005. ref SDS 59 E13K.
601315 - ..
601316 - On 140430 0900 at 0400 letter to Doctor Egan Cardiology VA Clinic
601317 - Martinez agenda for meeting 0900, ref SDS 83 HY6O, report patient
601318 - history of lipid labs, ref SDS 83 PT53, may show discordance with
601319 - LDL-P low and LDL-C high, indicating low risk CVD. ref SDS 83 PT6N
601321 - ..
601322 - On 140430 0900 at 0400 letter to Doctor Egan Cardiology VA Clinic
601323 - Martinez agenda meeting at 0900 reported maintained training protocol
601324 - hiking 11 miles daily, along with low-carb diet training for hiking
601325 - Half Dome on 140917. Weight has reached 164, as shown in patient
601326 - history, but is most often about 170 after hiking. ref SDS 83 PU34
601328 - ..
601329 - On 140430 0900 at 0900 meeting Doctor Egan Cardiology VA Clinic
601330 - Martinez discussed CTA imaging tests to assess regression of
601331 - atherosclerosis plaque, ref SDS 83 2F6O, that required CABG +4 on
601332 - 091022 0700, ref SDS 7 PQWU, as considered previously with the VA
601333 - during the meeting in San Francisco on 140213 0830, ref SDS 74 JZ4O,
601334 - and cited in the letter on 140312 1720. ref SDS 82 PSXX Doctor Egan
601335 - seemed to indicate that patient history of CABG +4 surgery 5 years ago
601336 - on 091022, makes evaluating regression of atherosclerosis unnecessary
601337 - to adjust prescribed care of medication and extended exercise for the
601338 - purpose of saving and money, and reducing painful side effects.
601339 - ref SDS 83 OK7L
601341 - ..
601342 - On 140430 0900 meeting Doctor Egan Cardiology VA Clinic Martinez
601343 - reported hiking stresses left knee injured in a fall of 40' back in
601344 - 1973, causing degenerative arthritis. In past month or so, feet have
601345 - begun to hurt, so it remains a challenge to control CVD risk through
601346 - exercise. Glucosamine Chondroitin helps resolve some of this problem,
601347 - with the result that hiking this year is about 300 miles ahead of the
601348 - record hiking through the 1st 4 months of last year. ref SDS 83 PU37
601349 - Doctor Egan encouraged extended endurance hiking for lowering LDL
601350 - cholesterol and triglycerides and raising HDL that reduce CVD risk.
601351 - ref SDS 83 RI9N The doctor asked about resting heart rate,
601352 - ref SDS 83 297N, this has reduced to below 60, due to increased
601353 - endurance hiking, shown from patient history beginning on 140422,
601354 - shown in case study on 120101 0900. ref SDS 21 RQ6H
601356 - ..
601357 - On 140430 0900 meeting Doctor Egan Cardiology VA Clinic Martinez
601358 - reported slight and occasional dizziness when laying down and turning
601359 - my head. ref SDS 83 PU43 Overall health very good. CT study on
601360 - 130117 showed esophagus has finally returned to normal, without the
601361 - big bubble that was there for 5 years or so. Accordingly, VA has
601362 - provided outstanding health care. ref SDS 83 PU47
601364 - ..
601365 - On 140430 0900 letter from Doctor Egan, Cardiology Physician at
601366 - Martinez Clinic, notes medical team did not address elevated potassium
601367 - in labs, and again notifies that this condition represents exposure to
601368 - "electrical problems" with the heart. ref SDS 83 UV5I
601370 - ..
601371 - On 140505 0936 Doctor Egan notified that medical team at VA Medical
601372 - Center in San Francisco was advised of concerns on elevated potassium
601373 - (K) and Total Bilirubin, ref SDS 84 YV4L, shown in labs reported in
601374 - the record on 140203 1147. ref SDS 71 ZG5O
601376 - ..
601377 - On 140508 1133 lab for VA from Labcorp at John Muir Clinic shows
601378 - glucose, sodium at high end of range, and shows potassium and T bili
601379 - above range, ref SDS 85 WJ5H, indicating influence of extended
601380 - endurance hiking 22 miles the day before, and another 11 miles morning
601381 - of the blood draw, and possibly caused by statin and ezetimibe
601382 - treatment to lower LDL cholesterol, as discussed in Notes of the lab
601383 - on 140508 1133. ref SDS 85 G34G Lipid panel shows further improvement
601384 - with LDL-P 851 down 10 points and HDL 67 up 6 points from 4 months
601385 - earlier. ref SDS 85 BE6O Improved lipid history, ref SDS 85 W25L,
601386 - reveres prior history of worsening lipids occurring after significant
601387 - improvement, and is attributed to increased endurance hiking 300 miles
601388 - per month and adding orange juice at approximately 500 ml per day.
601389 - ref SDS 85 I17G
601391 - ..
601392 - On 140514 0950 lab at VA Medical Center in San Francisco to support
601393 - meeting with Doctor Alba on 140519. ref SDS 86 X45G Excellent lipid
601394 - lab, ref SDS 86 IM9N, aligns with Labcorp blood test using NMR
601395 - technology last week on 140508 1133. ref SDS 85 5C7M Reflects
601396 - increased hiking and weight control past 3.5 months, reported in case
601397 - study on 120101 0900, ref SDS 21 PYXR, and supported with low carb
601398 - diet (including orange juice) and low dose medication, reported on
601399 - 140513, in the same study. ref SDS 21 ZU5G Favorable results seemed
601400 - "too good to be true" and so the VA lab did a second test to
601401 - corroborate findings shown by (a) and (b) scores. ref SDS 86 5C7M
601403 - ..
601404 - On 140515 2043 letter to VA submits consolidated results of Labcorp
601405 - test on 140508 with VA test on 140514, noting continued favorable
601406 - lipid panel improves patient history past 3 years of worsening results
601407 - after significant improvement. ref SDS 87 1V6M
601409 - ..
601410 - On 140515 2043 letter to VA submits reports meeting with Doctor Egan
601411 - in Cardiology at Martinez Clinic on 140430. ref SDS 87 YM67 After the
601412 - meeting, the doctor wrote a letter noting again that potassium (K) was
601413 - elevated in lab on 140203, and cited risk of "electrical problems" for
601414 - CAD patients (see line 392120. ref SDS 83 UV5I
601416 - ..
601417 - On 140515 2043 letter to VA reports that on 140513, weight dropped to
601418 - 163, lowest in 30 years, after hiking another 1000 miles since prior
601419 - labs in February, ref SDS 87 YM82, see case study (see line 105253
601420 - shown on 120101 0900. ref SDS 21 PYXR
601422 - ..
601423 - On 140515 2043 letter to VA reports medication side effects slight
601424 - dizziness in past month when laying down and turning my head left or
601425 - right. There may also be increased urination the past month or so,
601426 - but this is hard to track. Seem to be getting up a lot during the
601427 - night, as occurred with Rosuvastatin, but could be imagination - not
601428 - sure yet. ref SDS 87 YM98
601430 - ..
601431 - On 140515 2043 letter to VA requests coronary CTA with calcium score
601432 - to evaluate regression of atherosclerosis. ref SDS 87 YM41 Further
601433 - requests EPC lab to assess favorable conditions along with elevated
601434 - HDL for regression of atherosclerosis. ref SDS 87 YM61
601436 - ..
601437 - On 140515 2043 letter to VA reports labs show excellent care at the VA
601438 - achieving favorable results lowering CVD risk for continuing cycles.
601439 - As noted initially, in past years, whenever HDL increased and
601440 - Triglycerides dropped, on the next test the numbers got worse, see
601441 - patient Lipid History Trend Analysis on 140508 (line 610726.
601442 - ref SDS 86 W25L Thanks to skill and persistence of the VA medical
601443 - team, this time the numbers improved. ref SDS 87 YM64
601445 - ..
601446 - On 140518 2120 letter submits agenda to Doctor Alba for meeting
601447 - tomorrow on 140519, at VA Medical Center in San Francisco. ref SDS 88
601448 - 1V6M Medication side effects of dizziness seems to have subsided.
601449 - ref SDS 88 DV50 Very dry mouth in the night past week, and frequency
601450 - of urination has further increased, indicating dehydration issue,
601451 - possibly associated with elevated bilirubin. ref SDS 88 DV56
601452 - Peripheral neuropathy has returned, possibly related to bilirubin.
601453 - Follows prior pattern with Rosuvastatin, but at this time the problem
601454 - is very minor, only a few occasions the past 2 weeks or so.
601455 - ref SDS 88 DV59
601457 - ..
601458 - On 140519 0800 meeting at VA Doctor Alba ordered another lab to test
601459 - potassium and other electrolytes. ref SDS 89 HY6O Doctor pleased
601460 - patient implemented prescribed care to continue physical activity that
601461 - yielded favorable lipid labs to lower CVD risk. ref SDS 89 X59G
601462 - Hiking 300 miles per month lowered weight, lowered triglycerides and
601463 - increased HDL 67, also aided with orange juice. ref SDS 89 MY7J
601464 - Elevated EPC and HDL labs enable rapid regression of atherosclerosis
601465 - to lower CVD risk. Coronary CTA and calcium score standard of care
601466 - testing response to treatment for regression of atherosclerosis.
601467 - ref SDS 89 IW6L VA concerned anatomy changes from CABG surgery 5
601468 - years ago makes CTA difficult. ref SDS 89 J83H Research indicates
601469 - coronary CTA test is standard of care to evaluate post-CABG patient
601470 - response to treatment 5 years later. ref SDS 89 OF7N Medication with
601471 - Atorvastatin 10 mg and Ezetimibe 10 mg and hiking 300 miles per month
601472 - cause adverse side effects. ref SDS 89 PC8K Doctor Alba explained
601473 - patients must tolerate adverse side effects in order to benefit from
601474 - line of care. ref SDS 89 A58I Favorable results testing with coronary
601475 - CTA with calcium score may support reducing prescribed care to reduce
601476 - debilitating side effects, if atherosclerosis has declined below
601477 - detectable levels. ref SDS 89 635O
601478 -
601479 -
601480 -
601482 - ..
6015 -
6016 -
6017 - Progress
6018 -
6019 -
601901 - Meeting Endocrinology Clinic VA Medical Center San Francisco
601902 - Hyperlipodemia Review Labs Medical Examination Vaccination Flu
601903 - Vaccination Flu Influenza Virus During Vitals Meeting Review Lipids
601904 - Flu Vaccination Influenza Virus During Vitals Meeting Review Lipids
601905 -
601906 - Follow up ref SDS 89 HY6O, ref SDS 88 DV4M.
601907 -
601908 - During check in to get vitals, the nurse gave an injection for
601909 - vaccination to protect against getting flu, also called influenza
601910 - virus.
601912 - ..
601913 - Doctor Rao introduced herself, following up telecon 2 days ago, when
601914 - she delayed the meeting today from 0830 to 0900, reported on 141022
601915 - 1523, ref SDS A6 IF5M
601917 - ..
601918 - Doctor Rao reported that Doctor Alba contacted her this morning about
601919 - the letter sent to the medical team yesterday, on 141024 0003,
601920 - ref SDS A7 IF5M, transmitting composite labs with agenda for meeting
601921 - this morning.
601923 - ..
601924 - Doctor Rao said she checked her computer yesterday, and found she did
601925 - not get the letter, so she requested and received a copy this morning
601926 - from Doctor Alba.
601928 - ..
601929 - Explained the letter was submitted very early this morning on 141024
601930 - 0003. ref SDS A7 IF5M
601932 - ..
601933 - Doctor Rao then checked her computer during the meeting and found the
601934 - letter with the agenda for meeting this morning. ref SDS A7 IF5M
601936 - ..
601937 - Assisted Doctor Rao openning the composite lab report cited in the
601938 - letter today with the agenda, and showing the VA lab on 141021 at
601939 - 1148, for comparison with results of Labcorp blood test an hour
601940 - earlier at 1021. ref SDS A5 U45J
601942 - ..
601943 - Doctor Rao deferred discussion of persistent elevated WBC cited in the
601944 - agenda to the meeting with EGD Department for the procedure scheduled
601945 - in 2 weeks next month on 141107, also shown in the agenda. ref SDS A7
601946 - ZT88
601947 -
601949 - ..
601950 - VA Success Managing Cholesterol for Regression Atherosclerosis
601951 - Hyperlipidemia Cholesterol Controlled Exercise Diet Medication
601952 - Cholesterol Managed Clinical Trial Exercise Diet Medication
601953 - Clinical Trial Considered Lower Cholesterol Without Statin Drugs
601954 -
601955 - Follow up ref SDS 89 X59G, ref SDS 74 HY6O.
601956 -
601957 - The doctor was pleased progress occurred this cycle with LDL-C 90
601958 - declined from 92 in the VA test and LDL-C 86 declined from 87 in the
601959 - Labcorp test. These diagnostics align with VA guidance for LDL-C <
601960 - 131 and LDL-C < 100 under Labcorp guidelines, shown in composite lipid
601961 - lab repored on 141021 1150. ref SDS A5 5C7M
601963 - ..
601964 - We reviewed the record showing LDL-C < 100 has been consistent the
601965 - entire year taking Atorvastatin 10 mg and Ezetimibe 10 mg. This
601966 - significantly improves prior results, when LDL-C initially declined
601967 - below 100 then increased above 200, first taking Simvastatin 40 mg,
601968 - and Rosuvastatin 20 mg, over the prior 3 years from 2010 - 2013, shown
601969 - in patient lipid history summarized in the record reviewing labs on
601970 - 141021. ref SDS A5 W25L
601971 -
601972 -
601974 - ..
601975 - CVD Risk Highest LDL-P 1586 Increases 100% and LDL-C 90 low
601976 - LDL-P Borderline High Increases 100% with Low LDL-C Highest Risk CVD
601977 -
601978 - Doctor Rao advised that she and Doctor Alba are very concerned that
601979 - LDL-P 1586 increased nearly 100% to "borderline high" - well above
601980 - prior levels < 1000, compared to the prior Labcorp blood test on
601981 - 140508 showing LDL-P 851. This reverses significant improvements in
601982 - lipid profile reported in the meeting with Doctor Alba at the VA on
601983 - 140519 0800. ref SDS 89 X59G
601985 - ..
601986 - We reviewed discussions during the prior meeting with Doctor Alba on
601987 - 140519, considering research reporting "high" LDL-P with "low" LDL-C
601988 - present the highest risk for cardiovascular disease (CVD), ref SDS 89
601989 - T97N, citing the record on 131219 0930, ref SDS 62 GO35
601990 -
601991 -
6020 -
SUBJECTS
Default Null Subject Account for Blank Record
6103 -
610401 - ..
610402 - Medication and Diet Changes Discussed to Lower LDL-P < 1000
610403 -
610404 - Doctor Rao advised that Doctor Alba suggests diet changes to lower
610405 - LDL-P 1586, reported in Labcorp NMR lipid test on 141021, shown with
610406 - VA lab (that omits LDL-P test) performed an hour later the same day on
610407 - 141021 1150. ref SDS A5 U45J
610409 - ..
610410 - Doctor Rao reviewed a few entries in patient history showing daily
610411 - diet, medication, exercise and vitals, set out in case study on 120101
610412 - 0900. ref SDS 21 4G4O She suggested switching from 2% to 1% or even
610413 - skim milk. Explained drinking 2 gallons of milk a month. The doctor
610414 - further suggested removing yokes from eggs. Explained eating
610415 - approximately 2 eggs per week over 2 month procurement cycles. There
610416 - was further suggestion to eat 2 rather than 3 eggs in omlettes
610417 - (usually comprised of cheese and onion, and sometimes asparagus and
610418 - avocado).
610420 - ..
610421 - Research on 131125 reported cardiology literature explaining that
610422 - eating food has little effect on cholesterol levels in blood.
610423 - ref SDS 58 PQ6G
610425 - ..
610426 - Doctor Rao discussed increasing Atorvastatin 10 mg to 20 mg in order
610427 - to reduce LDL-C < 70, a VA protocol goal in this case reported in
610428 - Progress Notes for the prior meeting on 140519 0800. ref SDS 89 OW3K
610430 - ..
610431 - We reviewed the record showing VA published "goal" <= 130, and Labcorp
610432 - "goal" < 100, all shown in consolidated results on 141021 1150.
610433 - ref SDS A5 5C7M Recent guidance published by American Heart
610434 - Association - AHA - shows LDL-C "goal" < 190, reported on 131112 1422.
610435 - ref SDS 53 HT87
610437 - ..
610438 - Since LDL-C 90 in the recent VA lab on 141021, 141021 1150,
610439 - ref SDS A5 5C7M, actually declined to the lowest level in 8 years at
610440 - the VA, and further since lipid history shows LDL-C < 100 has remained
610441 - steady the past 12 months, ref SDS A5 W25L, with the current regimin
610442 - of Atorvastatin 10 mg and Ezetimibe 10 mg, and finally since statin
610443 - medications have little effect on LDL-P, it was decided to continue
610444 - the current medication prescription.
610445 -
610447 - ..
610448 - Physical Activity Hike 300 Miles Per Month Prescription Lower CVD Risk
610449 - Weight Lowest 30 Years Prescribed Low Carb Diet and Physical Activity
610450 - Prescribed Care Implemented Rigorously through Doctor Patient Collaboration
610451 -
610452 - Follow up ref SDS 89 MY7J.
610453 -
610454 - Doctor Rao was disappointed that reduced exercise caused increased
610455 - weight to 186 on 141011, shown in case study of diet, medication,
610456 - exercise and vitals listed in the record on 120101 0900. ref SDS 21
610457 - PUWT This was a significant increase from 163 on 140513, ref SDS 21
610458 - ZU5G, at the time of the prior labs reported the next day on 140514
610459 - 0950. ref SDS 86 IM9N
610461 - ..
610462 - The doctor noted increased physical activity this year reduced weight
610463 - to 163, the lowest in 30 years, reported in a letter to the VA on
610464 - 140515 2043. ref SDS 87 YM82 This correlates with falling LDL-P 851
610465 - and rising HDL 67, both best lipid results in patient history recorded
610466 - this past May. Results since May 14, of rising LDL-P 1586 and falling
610467 - HDL 57, shown in patient Lipid History on 140121, ref SDS A5 W25L,
610468 - require adjusting patient care...
610470 - ..
610471 - Collection DT CHOL TRIGL HDL LDL-C LDL-P HDL-P LDL-P SIZE SCORE LDL-D
610472 - 10/21/2014 11:48 159 65 57 90 ............... ........................
610473 - 10/21/2014 10:21 157 80 55 86 .1586....36.4.. 1277...19.7......46.....
610474 - 10/20/2014 10:50 174 79 61 96 ............... ........................
610475 - 08/14/2014 15:28 161 72 55 92 ............... ........................
610476 - 05/14/2014 10:16 164 58 66 87 ............... ..................... 93
610477 - 05/08/2014 11:49 162 59 67 83 851 38.1 < 90 21.2 < 25 .....
610478 - 02/03/2014 12:28 160 H 47 58 93 ............... ........................
610479 - 02/01/2014 12:31 156 68 61 81 861 31.4 < 90 21.3 < 25 .....
610480 - 10/15/2013 08:25 321 H 109 50 249 H ........................................
610481 - 05/29/2013 08:18 307 H 85 50 240 H ........................................
610482 - 02/28/2013 08:39 310 H 73 47 248 H ........................................
610483 - 11/30/2012 10:01 173 53 57 105 ........................................
610484 - 08/31/2012 15:25 176 94 47 110 ........................................
610485 - 05/09/2012 11:24 158 76 49 94 ........................................
610486 - 02/09/2012 11:18 285 82 41 228 H ........................................
610487 - 11/17/2011 14:27 260 84 43 200 H ........................................
610488 - 07/27/2011 12:58 163 81 45 102 ........................................
610489 - 12/07/2010 09:17 151 41 47 96 ........................................
610490 - 07/21/2010 08:54 261 H 87 35 L 209 H ........................................
610491 - 06/10/2010 10:33 217 H 83 36 L 164 H ........................................
610492 - 12/14/2009 11:10 241 H 136 44 170 H ........................................
610493 - 08/13/2009 15:09 233 H 118 30 L 179 H ........................................
610494 - 06/16/2006 10:59 238 H 68 32 L 192 H ........................................
610495 -
610497 - ..
610498 - Patient history shows weight loss and improved lipid history correlate
610499 - with increased physical activity beginning in October of last year...
610501 - ..
610502 - Hiking Mileage 2013
610503 -
610504 - 130127....Jan................. 168 2607 ...... ref SDS 21 OQ4J
610505 - 130303....Feb................. 111 1791 ...... ref SDS 21 PO6I
610506 - 130331....Mar................. 78 1238 ...... ref SDS 21 866M
610507 - 130428....Apr................. 140 2224 ...... ref SDS 21 Q48M
610508 - 130602....May................. 302 4838 ...... ref SDS 21 QG3F
610509 - 130630....Jun................. 89 1428 ...... ref SDS 21 765L
610510 - 130728....Jul................. 172 2752 ...... ref SDS 21 T78G
610511 - 130902....Aug................. 297 4916 ...... ref SDS 21 554N
610512 - 130929....Sep................. 225 4305 ...... ref SDS 21 419J
610513 - **** 131103....Oct................. 373 5757 ...... ref SDS 21 6F9N
610514 - 131201....Nov................. 172 2899 ...... ref SDS 21 XRPV
610515 - 131229....Dec................. 234 3324 ...... ref SDS 21 XXQY
610517 - ..
610518 - Hiking Mileage 2014
610519 -
610520 - 140202....Jan................. 347 5393 ...... ref SDS 64 YWST
610521 - 140202....Jan................. 347 5393 ...... ref SDS 64 YWST
610522 - 140302....Feb................. 234 3681 ...... ref SDS 64 PYWS
610523 - 140330....Mar................. 207 3313 ...... ref SDS 64 RXPR
610524 - 140427....Apr................. 310 4402 ...... ref SDS 64 RXVV
610525 - 140601....May................. 322 5338 ...... ref SDS 64 SXWV
610526 - 140629....Jun................. 156 2337 ...... ref SDS 64 ZW4N
610527 - 140803....Jul................. 81 1023 ...... ref SDS 64 I37G
610528 - 140831....Aug................. 140 1998 ...... ref SDS 64 236I
610529 - 140928....Sep................. 136 2855 ...... ref SDS 64 XWUY
610530 - 141102....Oct................. 215 3540 ...... ref SDS 64 F56L
610532 - ..
610533 - Favorable lipid labs on 140203, correlate with hiking 347 miles during
610534 - Janury. Lipids improved further on 140514, which correlates with
610535 - hiking 300 miles again in April and May. Equally, weight gain and
610536 - negative lipids in the current labs on 141021, correlate with
610537 - significantly reduced hiking this cycle from June to October, due to
610538 - side effects of treatment hiking 300 miles per month.
610540 - ..
610541 - Improved lipid labs on 140203 - lowering LDL-P below 1000, and
610542 - increasing HDL above 60 - correlate with increased hiking during
610543 - December 2013, through January 2014, and which implemented research on
610544 - 131125, that indicates excess weight (i.e., metabolic syndrom)
610545 - increases risk for CVD. Additionally, lowering LDL-P < 1000 also
610546 - reduced the risk of CVD caused by discordance between high LDL-P and
610547 - low LDL-C, as follows...
610548 -
610549 - Among discordant patients in the Framingham Offspring Study the
610550 - group with the highest risk for future cardiovascular events
610551 - had high LDL-P and low LDL-C, while the group with the lowest
610552 - risk had low LDL-P but higher LDL-C. Many patients with the
610553 - metabolic syndrome or type-2 diabetes have the type of
610554 - discordance where LDL-P is elevated but LDL-C may be close to
610555 - normal. In these individuals, measurements of LDL-C may
610556 - underestimate cardiovascular risk. Measurements of ApoB or
610557 - LDL-P may therefore be helpful in these individuals.
610558 - ref SDS 58 C347
610560 - ..
610561 - Clinical trial of patients training on a stationary bicycle (Universal
610562 - Aerobicycle) 3 - 4 days per week for 50 minutes evaluated minimal
610563 - "endurance" training" for lowering triglycerides (TG) and raising HDL,
610564 - reported on 131125 0005, ref SDS 58 4L5O
610566 - ..
610567 - The same research on 131125, found weight loss and triglycerides are
610568 - sensitive to exercise. ref SDS 58 R465 Some authorities report the
610569 - body consumes tryglycerides for energy with even moderate exercise
610570 - performed consistently for more than 30 minutes a day. ref SDS 58 T68I
610572 - ..
610573 - HDL lipids are generally not improved with exercise at commonly
610574 - recommended levels, i.e., < 30 miles per week, again reported in
610575 - research on 131125. ref SDS 58 SU36 This research aligns with patient
610576 - history presented in a letter to the medical team on 140520 0732,
610577 - showing patient HDL was not appreciably increased by moderate exercise
610578 - over the past 4 years. ref SDS 90 VQ51
610580 - ..
610581 - Clinincal studies seem to indicate hiking longer distances at faster
610582 - speed can reduce weight and raise HDL. ref SDS 58 EK5N During the
610583 - meeting today, Doctor Rao was pleased that HDL 30 reported 5 years ago
610584 - at the time of heart bypass surgery (CABG +4) on 091022 0700.
610585 - ref SDS 7 PQWU, more than doubled to HDL 61 in the Labcorp blood test
610586 - on 140201, ref SDS 86 5C7M; and, that this increase improved further
610587 - to HDL 67 shown in VA lab 5 months ago on 140514 (which aligned with
610588 - Labcorp Lab performed by Liposcience a week earlier on 140508).
610589 - ref SDS 0 415J
610591 - ..
610592 - HDL rising over 100% correlates with increasing hiking from < 30 miles
610593 - per week to 60 - 90 miles per week, ref SDS 0 C88F, set out in the
610594 - letter to the VA on 140520 0732. ref SDS 90 VQ51
610596 - ..
610597 - Analysis on 140514, of increasing HDL 30 to HDL 67 also cited
610598 - consuming orange juice at the rate of 541 ML/day, ref SDS 86 LO4J,
610599 - consistent with research on 131125 0005. ref SDS 58 K34L
610601 - ..
610602 - After the meeting at the VA on 140519, exercise hiking 300 miles per
610603 - month became increasingly difficult due to rising side effects of
610604 - metatarsalgia injuries that cause severe pain in the feet. ref SDS 89
610605 - CC8O Progressive side effects beginning in February, were reported in
610606 - a letter to the VA, and discussed during a meeting with Doctor Egan in
610607 - Cardiology at the VA Clinic in Martinez, on 140430 0900. ref SDS 83
610608 - PU37
610610 - ..
610611 - After meeting with Doctor Egan on 140430, Doctor Alba examined the
610612 - feet 3 weeks later, during a meeting on 140519, at the VA Medical
610613 - Center in San Francisco. Doctor Alba discussed referral to the
610614 - Podiatry Department for resolving side effects to maintain treatment
610615 - hiking 300 miles per month that lowers CVD risk by improving lipids
610616 - and driving regression of atherosclerosis. ref SDS 89 YM5N The next
610617 - day on 140520, letter to Doctor Alba at the VA Medical Center in San
610618 - Francisco confirmed requirements for resolving side effects in order
610619 - to continue hiking 300 miles per month to lower CVD risk. ref SDS 91
610620 - VQ51
610622 - ..
610623 - During the meeting on 140519, Doctor Alba explained medical practice
610624 - encourages patients to tolerate side effects of treatment in order to
610625 - maintain benefits recovering from serious maladies like cancer,
610626 - cardiovascular disease (CVD), diabetes, etc. ref SDS 89 A58I
610628 - ..
610629 - None-the-less on 140731, Doctor Alba made referral to Podiatry to
610630 - evaluate side effects of treatment hiking 300 miles per month.
610631 - ref SDS 98 4230
610633 - ..
610634 - Today, Doctor Rao was pleased that Doctor Alba's work plan to order
610635 - support in Podiatry has begun to be effective, enabling treatment to
610636 - resume with endurance exercise hiking 300 miles per month, reported in
610637 - the letter submitting the agenda for the meeting today. ref SDS A7
610638 - ZT4L We briefly reviewed patient history beginning on 141110, showing
610639 - daily diet, exercise, vitals, and medication. Hiking has finally
610640 - increased back to 11 miles per day, though still interrupted by
610641 - blister problems. 140101 0600, ref SDS 64 PUWT
610642 -
610643 -
6107 -
SUBJECTS
Default Null Subject Account for Blank Record
6203 -
620401 - ..
620402 - VA Proposes Increases Statin Drug Treatment Improve Lipid Profile
620403 - Atorvastatin Ezetimibe Reduce Side Effects by Reducing Dose
620404 - Side Effects Reduced by Reducing Treatment with Regression Atherosclerosis
620405 - Regression Atherosclerosis Lowers CVD Risk Reduce Treatment Reduce Side Effects
620406 -
620407 - Follow up ref SDS 89 PC8K, ref SDS 74 A36K.
620408 -
620409 - Atorvastatin side effects are listed on 130603 0930. ref SDS 46 PC6O
620410 - Ezetimibe side effects are listed on 131125 0005. ref SDS 59 GD8G
620412 - ..
620413 - Doctor Rao advised that Doctor Alba called her this morning, and
620414 - recommended increasing treatment with statin drugs to improve lipid
620415 - profile increasing HDL and lowering LDL-P.
620417 - ..
620418 - Reviewed research showing statins have little effect on HDL, reported
620419 - on 131125 0005. ref SDS 58 KG9F Moreover, statins have less effect on
620420 - LDL-P than on LDL-C, also reported on 131125 0005. ref SDS 58 S34G
620422 - ..
620423 - On discussion, decided to maintain current medication dose in order to
620424 - avoid increasing already difficult side effects, discussed previously
620425 - with Doctor Alba on 140519 0800. ref SDS 89 PC8K
620427 - ..
620428 - Will try to continue reducing side effects of treatment hiking 300
620429 - miles per month in order to restore former favorable lab profiles.
620430 - Will order alternate hiking shoes to prevent blisters and
620431 - metatarsalgia. Further expect Podiatry orthotic insert remedies to
620432 - relieve metatarsalgia pain.
620434 - ..
620435 - Restoring former level of effort hiking 300 miles per month aligns
620436 - with research on 131125 indicating extended endurance exercise
620437 - increases HDL. ref SDS 58 SH50 This treatment in conjunction with
620438 - lowering carbohydrates also lowers triglycerides, weight, ref SDS 58
620439 - T68I, and LDL-P. ref SDS 58 QP9F
620441 - ..
620442 - [On 141026 1617 ordered Hoka Stinson Lite shoes to replace
620443 - defective Hoka Stinson Trail shoes that caused severe
620444 - blisters. ref SDS A8 XN5F
620446 - ..
620447 - [On 141030, reported in case study on 140101, received new
620448 - Hoka Stinson Lite shoes and wore on hike at Lafayette
620449 - Reservoir with VA Prolab orthotic inserts - perfect hike
620450 - with no blisters and no metatasalgia pain. ref SDS 64 OZ6F
620451 -
620452 -
620453 -
620454 -
620455 -
6205 -
SUBJECTS
Default Null Subject Account for Blank Record
6303 -
630401 - ..
630402 - Feet Pain Metatarsalgia Podiatry Referral Regression Atherosclerosis
630403 - Podiatry Resolve Metatarsalgia Feet Pain Maintain Regression Atherosclerosis
630404 - Atherosclerosis Podiatry Resolve Metatarsalgia Feet Pain Side Effects Physical Activity
630405 -
630406 - Follow up ref SDS 89 CC8O.
630407 -
630408 -
630409 -
630410 -
630411 -
6305 -
SUBJECTS
Default Null Subject Account for Blank Record
6403 -
640401 - ..
640402 - Atherosclerosis Regresses Rapidly Elevated HDL and EPCs
640403 - CTA Test Response Treatment Favorable Results Reduce Treatment Side Effects
640404 -
640405 - Follow up ref SDS 89 635O. ref SDS 89 IW6L.
640406 -
640407 - Research on 131125, further found that elevated HDL cholesterol
640408 - produced in the liver, together with circulating endothelial
640409 - progenitor cells (EPCs) produced in the bone marrow, both driven by
640410 - extended endurance exercise, ref SDS 58 6O9M, are pathophysiological
640411 - conditions for rapid regression of atherosclerotic plaques,
640412 - ref SDS 58 HG90, thus lowering CVD risk.
640414 - ..
640415 - Discussed ordering standard of care to test for response to treatment
640416 - using coronary CTA with calcium score, reviewed with Doctor Alba
640417 - during the meeting at the VA Medical Center on 140519 0800.
640418 - ref SDS 89 635O Favorable test results yield evidence to reduce
640419 - treatment that in turn reduces onerous side effects of medication,
640420 - ref SDS 89 PC8K, and endurance exercise. ref SDS 89 CC8O
640422 - ..
640423 - Doctor Rao disclosed that she has experience ordering coronary CT
640424 - angiography testing.
640426 - ..
640427 - She seemed to say that even if CCTA testing finds no evidence of
640428 - atherosclerotic plaques, the patient would require continuing current
640429 - treatment, because there could be pervasive plaques in blood vessels
640430 - that are not found with testing. Doctor Rao advised that patients
640431 - must tolerate side effects in order to benefit from effective
640432 - treatments.
640434 - ..
640435 - This in part aligns with Doctor Alba's analysis on 140519, saying
640436 - patients must tolerate side effects to benefit from treatments.
640437 - ref SDS 89 A58I
640439 - ..
640440 - The proposition that CCTA testing finding no evidence of
640441 - atherosclerotic plaques would not support adjusting treatment to
640442 - reduce debilitating side effects with standard of care to align
640443 - treatment with evidence of improved medical condition, also, discussed
640444 - with Doctor Alba, citing Millie's treatment was reduced to reduce
640445 - onerous side effects, when CT tests and labs showed her cancer
640446 - significantly declined, reported on 140519 0800. ref SDS 89 VO5N
640447 - Cancer is more pervasive than aterhosclerosis, and much more dangerous
640448 - with less time to recover on recurrance. Atherosclerosis takes 30 or
640449 - more years to progress. Cancer takes mere months.
640451 - ..
640452 - Generally, if CCTA finds atherosclerosis sufficient to cause angina
640453 - (heart pain) has been regressed to 0, it seems reasonable that
640454 - treatment causing this regression of maximum atherosclerosis plaque,
640455 - would equally regress less severe plaques that might have previously
640456 - existed.
640458 - ..
640459 - Doctor Rao further repeated analysis presented by Doctor Feingold
640460 - during the prior meeting at the VA Medical Center on 140519, saying
640461 - patients who have undergone heart bypass surgery, here CABG +4 on
640462 - 091022, cannot be evaluated with CCTA because surgical changes to
640463 - anatomy prevent obtaining reliable results. ref SDS 89 J83H Doctor
640464 - Alba presented this policy position again in a subsequent letter on
640465 - 140612 1048. ref SDS 94 X45G
640467 - ..
640468 - During the meeting referenced Doctor Rao to the record on 140519,
640469 - showing CCTA is standard of care to assess response to treatment
640470 - recovering from atherosclerosis. ref SDS 89 OF7N Cited letter to the
640471 - VA on 140626 1652, presenting case study showing coronary CTA common
640472 - medical practice to evaluate response to treatment testing for
640473 - regression atherosclerosis after CABG heart bypass surgery.
640474 - ref SDS 96 MZ54
640476 - ..
640477 - Asked Doctor Rao to meet with the Radiology Department here at the VA
640478 - Medical Center in San Francisco to inquire about feasibility of
640479 - performing CCTA in light of case study discussed with Doctor Alba on
640480 - 140519, and submitted in a letter to the doctor on 140629, showing
640481 - CCTA is standard of care to test for response to treatment with CABG.
640482 - ref SDS 95 MZ54
640483 -
640484 - [...below on 141024 0900 Progress Notes show addendum dated
640485 - 141028, relating Doctor Rao met with radiologist regarding
640486 - technical limitations of doing a CTA in patients with prior
640487 - CABG. Radiologist (Dr.Matt Barkovich) informed me that,
640488 - while a CAC score could be obtained, it would not be
640489 - accurate because the venous grafts in place after CABG are
640490 - in different planes, and these are not accounted for in the
640491 - planes that are set up for reading. ref SDS 0 1S4L
640492 -
640493 -
640494 -
640495 -
640496 -
640497 -
640498 -
6405 -
SUBJECTS
Default Null Subject Account for Blank Record
6503 -
650401 - ..
650402 - Medical Chart Progress Notes Meeting 140519 VA SF Medical Center
650403 -
650404 - Follow up ref SDS 89 476K, ref SDS 74 476K.
650405 -
650406 - On 140612 VA file from CD with Progress Notes for meeting on 140519
650407 - were received through US mail from VA Medical Center in San Francisco
650408 - ROI Department for request filed on 140519. Progress Notes were
650409 - signed on 140602. ref SDS 89 QQ5K
650410 -
650422 - ..
650423 - VA Progress Notes for meeting with Doctor Rao at VA Endocronology on
650424 - 141024 are stored in...
650425 -
650436 - ..
650437 - 1. LOCAL TITLE: ENDOCRINE ATTENDING PROGRESS NOTE (MED)
650438 - STANDARD TITLE: ENDOCRINOLOGY ATTENDING NOTEE
650439 - DATE OF NOTE: OCT 24, 2014@09:040
650440 - ENTRY DATE: OCT 24, 2014@09:04:30
650442 - EXP COSIGNER:
650443 - URGENCY:
650444 - STATUS: COMPLETED
650446 - ..
650447 - 2. HPI
650448 -
650449 - 1. ID: 69 year old male with CAD (s/p CABG 2009) and
650450 - achalasia, here for f/u of hyperlipidemia. Pt last seen in
650451 - endocrine clinic 5 mths ago.
650453 - ..
650454 - 2. Pt was started on Simvastatin about 3 years ago. LDL
650455 - decreased from 180-->96, but he developed "left shoulder
650456 - myopathy"- described as pain and inability to raise
650457 - shoulder above 90 degrees.
650459 - ..
650460 - 3. No CPK on records. He was switched to Rosuvastatin, and
650461 - when dose was increased to 20 mg, he reported side effects
650462 - of sexual dysfunction, dizziness, dry mouth and right foot
650463 - numbness. Rosuvastatin was d/c'd in 12/2012, and
650465 - ..
650466 - 4. atorva (10 mg qd) started in 11/2013, with Zetia 10 mg qd
650467 - added in 12/2013
650469 - ..
650470 - 5. Since his last visit, pt states he has been doing well
650471 - except for pain in his foot due to hiking. He continues on
650472 - the atorva 10 mg qd+ zetia 10 mg qd.
650474 - ..
650475 - This section can be more helpful presenting examination in
650476 - Endocrinology for Podiatry referral to resolve painful metatarsalgia
650477 - in both feet shown in patient history on 140519, ref SDS 89 TW6O. On
650478 - 140520 0732 letter to VA Medical Center in San Francisco cited painful
650479 - side effects that prevent hiking to lower CVD risk. ref SDS 91 UT5M
650481 - ..
650482 - On 140629 1921 letter to VA reminds medical team referral to Podiatry
650483 - required to relieve metatarsalgia side effects of prescribed care.
650484 - ref SDS 97 U14H
650486 - ..
650487 - On 140731 Doctor Alba made referral to Podiatry to resolve
650488 - metatarsalgia pain in order to resume hiking that lowers CVD risk.
650489 - ref SDS 98 OV90
650491 - ..
650492 - On 140805 Doctor Tang in Podiatry Department reviewed patient history
650493 - hiking 300+ miles per month to lower CVD risk, ref SDS 99 556J Doctor
650494 - Tang prescribed ibuprofen to lower pain hiking. ref SDS 99 1E6R He
650495 - ordered custom orthotic inserts to reduce metatarsalgia injuries
650496 - during hiking. ref SDS 99 1F31
650498 - ..
650499 - On 140910 1553 patient received orthotic inserts ordered by Doctor
650500 - Tang for size 9.5 Hoka Stinson Trail shoes, during meeting at VA
650501 - Medical Center Podiatry Department in San Francisco. ref SDS A1 AK6J
650503 - ..
650504 - [On 141031 patient reports normal hiking 11 miles per day
650505 - finally achieved with orthotic inserts ibuprofen medication
650506 - and better shoes switching to Hoka Stinson Lite size 10
650507 - shoes, reported in case study on 140101 0600. ref SDS 64
650508 - IP9K
650510 - ..
650511 - Progress Notes Meeting 140124 0904 continues...
650512 -
650513 - 6. His dizzyness has resolved, and the peripheral neuropathy
650514 - has decreased significantly; of note, he was evaluated by
650515 - neurology (in 2/2013)for this.
650517 - ..
650518 - Report dizziness side effects resolved aligns with the letter sent to
650519 - the VA on 140518 2120. ref SDS 88 DV50 The same letter reported
650520 - peripheral neuropathy returned. ref SDS 88 DV59
650522 - ..
650523 - Progress Notes should cite authority for "patient reports" so there is
650524 - an audit trail in the record that supports patient status and care.
650525 - Mere representations are susceptible to error due to fungability of
650526 - human memory, noted by Andrew Groves in his book "Only the Paranoid
650527 - Survive," reviewed on 980307 1614. ref SDS 1 3668
650529 - ..
650530 - Progress Notes Meeting 140124 0904 continues...
650531 -
650532 - 7. He states he does have frequent urination though.
650533 -
650534 - 8. We subsequently discussed patient's diet and activity. His
650535 - hiking has decreased over the past few months due to foot
650536 - pain; however, he still hikes extensively, about 10-20
650537 - miles per week.
650539 - ..
650540 - Progress Notes should cite authority for reporting hiking mileage,
650541 - presented during the meeting today, shown above. ref SDS 0 FT8J
650542 - The doctor should further present correlation between decline of
650543 - hiking from 300 miles per month in April down to 80 miles in July.
650544 - Gradual recovery from metatarsalgia enabled increasing hiking back to
650545 - 215 miles per month in October.
650547 - ..
650548 - Progress Notes Meeting 140124 0904 continues...
650549 -
650550 - 9. Pt's weight has increased by almost 10 lbs over past 5
650551 - mths. This is partly a reflection of decreased activity,
650552 - and partly due to food choices. We reviewed his online
650553 - blog of diet....over the past 10 days, pt had eaten foods
650554 - with a significant saturated fat content on 8 out of the 10
650555 - days (ie, bacon, or pizza slice with extra cheese, or
650556 - ice-cream, or hamburger). He also drinks 2% milk
650558 - ..
650559 - Progress Notes should report orange juice was added to diet at
650560 - approximately 750 ML per day, shown in Progress Notes for prior
650561 - meeting on 140519 0800. ref SDS 89 OU47 supplements hiking for
650562 - increasing HDL 21% cited in clinical study reviewed on 131125 0005.
650563 - ref SDS 58 K34L Since hiking declined during past 5 months, orange
650564 - juice helped maingain HDL > 50, reported in lab on 141021 1150.
650565 - ref SDS A5 LO4J
650567 - ..
650568 - Progress Notes Meeting 140124 0904 continues...
650569 -
650570 - 3. Patient Medical History (PMH) and Patient Surgical History
650571 - (PSH)
650572 -
650573 - 1. Esophageal Achalasia - s/p lap heller myotomy and fundoplication 12/2009
650574 - - s/p EGD with dilations
650576 - ..
650577 - 2. CAD s/p CABG x4 in 2009
650579 - ..
650580 - 3. GERD
650582 - ..
650583 - 4. Hyperlipidemia
650585 - ..
650586 - 5. Left knee repair
650588 - ..
650589 - This note reflects entry in Progress Notes para 4, PSH, for meeting at
650590 - VA on 131121 0930. ref SDS 56 W49F
650592 - ..
650593 - Patient Medical History is shown in Progress Notes for meeting with
650594 - Doctor Egan in Cardiology on 140430 0900. ref SDS 83 TX50
650596 - ..
650597 - Progress Notes Meeting 140124 0904 continues...
650599 - ..
650600 - 4. MEDICATIONS:
650601 - Omeprazole 20 mg BID
650602 - Atorvastatin 10 mg po daily
650603 - Zetia 10 mg po daily
650605 - ..
650606 - 5. PHYSICAL EXAM
650607 - WT: 196.6 lb [89.4 kg] (10/24/2014 09:08)
650608 - HR: 58 (10/24/2014 09:08)
650609 - BP: 133/69 (10/24/2014 09:08)
650610 - Temp: 97.6 F [36.4 C] (08/28/2014 08:36)
650611 - RR: 20 (08/28/2014 08:36)
650612 - O2 Sat: 10/24/14 09:08:16 O97
650613 - BMI: 31.8 (Obesity Level I)
650614 - Gen=pleasant, comfortable male, NAD
650615 - HEENT=NCAT, op clear, anicteric, no LAD, no TM or nodules
650616 - Ext=no C/C/E
650618 - ..
650619 - 6. LABS:
650620 - Specimen Collection Date: Oct 21, 2014@11:48
650621 - EGFR 91 mL/min Ref: >=60 [662]
650622 - SODIUM 138 mmol/L 135 - 145 [662]
650623 - POTASSIUM 4.4 mmol/L 3.3 - 4.8 [662]
650624 - CHLORIDE 103 mmol/L 101 - 112 [662]
650625 - CARBON DIOXIDE 28 mmol/L 24 - 32 [662]
650626 - ANION GAP 7 mmol/L 5 - 20 [662]
650627 - UREA NITROGEN 22 mg/dL 10 - 24 [662]
650628 - CREATININE 0.84 mg/dL 0.6 - 1.3 [662]
650629 - GLUCOSE 110 mg/dl 65 - 115 [662]
650630 - CALCIUM 8.8 mg/dL 8.5 - 10.5 [662]
650631 - CHOLESTEROL 159 mg/dl 100 - 240 [662]
650632 - TRIGLYCERIDE 65 mg/dl 10 - 190 [662]
650633 - HIGH DENSITY LIPOPROT (HDL) 57 mg/dl Ref: >=35 [662]
650634 - LDL CHOL(Calculated) 90 mg/dl Ref: <=131 [662]
650636 - ..
650637 - Of note, we also reviwed the labs pt had done at LabCorp, which
650638 - he has cut and pasted onto his online website.
650640 - ..
650641 - VA System
650642 - May 8 2014 TC 162 LDL 83 HDL 67 TG 59
650643 - Feb 3rd 2014 TC 160 LDL 93 HDL 58 TG 47 HgA1c 5.5%
650644 - Labcorp TC 156 LDL 81 HDL 61 TG 61
650646 - ..
650647 - This section needs to be corrected showing lab source and dates.
650649 - ..
650650 - Progress Notes can be aided by listing recent labs on 141021, 141021
650651 - 1150, ref SDS A5 U45J, as follows...
650652 -
650653 - VA 141021 TC 159 LDL 90 HDL 57 TG 65
650654 - Liposcience TC 157 LDL 86 HDL 55 TG 80
650656 - ..
650657 - Progress Notes Meeting 140124 0904 continues...
650658 -
650659 - October 2013 TC 321 LDL 249 HDL 50 TG 85 TBil 1.7 Hga1c 5.5% CPOK 110 TSH 2.6
650660 - May 2013 TC 307 LDL 240 HDL 54 TG 85 TBil 1.3
650661 - November 2013 TC 173 LDL 105 HDL 57 TG 53 TBil 1.6
650662 -
650663 - 7. A/P
650664 -
650666 - ... is a 69 year old pleasant, engaged male with CAD,
650667 - achalasia and hyperlipidemia for which he is on atorva (10 qd)
650668 - and zetia (10 qd). Although his LDl has decreased by >50% on
650669 - the moderate dose statin + zetia, it is still above the ideal
650670 - goal of 70 at this time.
650672 - ..
650673 - Progress Notes should state the authority for "goal of 70."
650675 - ..
650676 - Progress Notes Meeting 140124 0904 continues...
650677 -
650678 - Furthermore, since the last visit, pt's HDL has decreased
650679 - slightly, LDL has increased slightly, and pt has had a 10-lb wt
650680 - gain--all in the setting of some decrease in exercise and
650681 - change in eating habits. Of note, although I have referred to
650682 - the calc LDL-c value, patient prefers to use the LDL-P value
650683 - which he obtains from Labcorp; that is fine, since both values
650684 - have changed in the similar direction.
650685 -
650686 - 1. Decrease LDL - Pt does not want to increase the atorva dose
650687 - to 20 mg qd. Instead, we have agreed that he will work on
650688 - losing the 10 lbs that he has gained and improving his diet
650689 - (ie, decrease foods with high content of saturated fats to
650690 - once every 10 days, rather than the current 8/10 days). Of
650691 - note, pt's TG level is fine.
650693 - ..
650694 - 2. Diet/Activity - Pt will work on increasing activity level
650695 - (as tolerated), changing diet and decreaseing wt as
650696 - discussed above. Given his ft pain, I suggested that pt
650697 - consider alternative ways of exercising (ie, swimming,
650698 - biking, etc).
650700 - ..
650701 - 3. We also discussed pt's request for CTA to assess regression
650702 - of atherosclerotic plaques; if this was noted, pt states
650703 - that it would justify altering our treatment (ie, d/c
650704 - statin or decrease exercise). However, I mentioned that
650705 - CTA is not indicated for a number of reasons:
650706 -
650707 - 1. Given the prior CABG with alteration in anatomy, CTA
650708 - would be difficult to read out appropriately;
650710 - ..
650711 - 2. pt has known CAD, and CTA is used clinically to
650712 - determine whether pt's do or do not have CAD;
650714 - ..
650715 - 3. CTA has risks, most notably with the contrast load and
650716 - risk of nephropathy, and, in his case, risks are not
650717 - worth the benefits;
650719 - ..
650720 - 4. even if CTA were to indicate regression of CAD plaques,
650721 - there is no published evidence that this would mean his
650722 - treatment regimen should be relaxed; to the contrary,
650723 - the current guidelines would indicate that his
650724 - treatment regimen should continue.
650726 - ..
650727 - Doctor Rao's Progress Notes generally align with discussion during the
650728 - meeting, per above. ref SDS 0 635O
650730 - ..
650731 - The doctor's 4th point can be supported with citation to history
650732 - applying current cardiology guidelines to patients showing regression
650733 - of atherosclerosis. If this is no evidence of patients regressing
650734 - atherosclerosis, there can be no "published evidence" on treatment
650735 - guidelines.
650737 - ..
650738 - This thorough and inciteful analysis should further correlate with
650739 - Millie's history of treatment for stage 5 cancer as a chronic disease.
650740 - When symptoms declined shown by cancer marker lab, CT radiology study
650741 - showing no evidence of cancer, and decline of IBC rash, treatment was
650742 - stopped in order to avoid painful side effects.
650744 - ..
650745 - Progress Notes Meeting 140124 0904 continues...
650746 -
650747 - Pt also request to have EPCs checked; we discussed that
650748 - this is a research test/protocol, and is not done
650749 - clinically, outside of research settings.
650751 - ..
650752 - Medical team constantly researches grounds for treatment. Research
650753 - shows that elevated HDL and EPCs drive regression of atherosclerotic
650754 - plaques.
650756 - ..
650757 - Progress Notes Meeting 140124 0904 continues...
650758 -
650759 - 4. Lastly, we reviewed Labcorp results (which are cut and
650760 - pasted into Mr.Welch's webpage). His WBC continues to be
650761 - elevated --will defer further w/u and management to his
650762 - PCP. Furthermore, pt's indirect bilirubin continues to be
650763 - mildly elevated (with other LFT's being WNL); will defer
650764 - management to pt's gastroenterologist. It is unlikely to
650765 - be 2/2 statin, since this would be an unusual patter with
650766 - statin therapy--ddx includes Gilbert's syndrome vs. other.
650767 - Pt's K level is WNL.
650769 - ..
650770 - 5. RTC in 4- 6 mths with fasting lipid panel.
650772 - ..
650773 - Addendum (10/28/14): As per Mr.Welch's request, I talked to
650774 - our radiologist here at the VA regarding technical limitations
650775 - of doing a CTA in patients with prior CABG. Radiologist
650776 - (Dr.Matt Barkovich) informed me that, while a CAC score could
650777 - be obtained, it would not be accurate because the venous grafts
650778 - in place after CABG are in different planes, and these are not
650779 - accounted for in the planes that are set up for reading.
650781 - ..
650782 - Doctor Rao's very commendable initiative investing personal time for
650783 - independent research on patient request, per above, ref SDS 0 M15N,
650784 - reflects elevated care at VA Medical Center San Francisco; it aligns
650785 - with Progress Notes, per above. ref SDS 0 WU8J This however is mere
650786 - conjecture about what might be determined from performing CCTA in this
650787 - case, and can only be actually determined by performing the test.
650789 - ..
650790 - There is no belief in cardiology that atherosclerosis can be
650791 - regressed, because there is no evidence anyone has done it. Equally,
650792 - there is no evidence presented by the VA to date that HDL can be
650793 - increased from 30 to 68, which is required to regress atherosclerosis;
650794 - yet in this case it has been done. Why then not test for response to
650795 - treatment?
650797 - ..
650798 - Progress Notes Meeting 140124 0904 continues...
650799 -
650800 - 8. Clinical Reminder Activity
650802 - ..
650803 - 9. MED REC NON PRIMARY CARE:
650804 -
650805 - Reconciliation of medications related to today's visit
650806 - completed, including non-VA medications and discrepancies, if
650807 - identified, were addressed. Medication changes and the
650808 - importance of medication management were reviewed with the
650809 - patient/caregiver today based on individual needs.
650810 - Patient/caregiver acknowledged understanding of instructions as
650811 - stated. An updated list of reconciled medications has been
650812 - provided to the patient/caregiver.
650814 - ..
650815 - List of medications is shown in Progress Notes para 4, above.
650816 - ref SDS 0 OV62
650817 -
650818 - /es/ Madhu Rao
650819 - Staff Physician
650820 - Signed 10/28/2014 10:57
650821 -
650822 -
650823 -
650824 -
650825 -
650826 -
650827 -
650828 -
650829 -
650830 -
650831 -
650832 -
650833 -
650834 -
650835 -
650836 -
650837 -