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 A1 0000. ref SDS 86 0000.
600502 -
600503 -
600504 -
600505 -
600507 - ..
6006 -
6007 -
6008 - Background
6009 -
6010 -
601001 - Lab on 131015, showing cholesterol remained high, 131015 0724,
601002 - ref SDS 47 BE6O, conflict with increased exercise and weight loss,
601003 - discussed in the letter to the medical team yesterday on 131016 1632.
601004 - ref SDS 48 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 49 T24N
601011 - ..
601012 - On 131017 1000 Doctor Egan proposed referring patient for clinical
601013 - trial to reduce cholesterol with new "targeted" drugs. ref SDS 49 179N
601015 - ..
601016 - On 131017 1000 VA medical chart Progress Notes assessment report
601017 - patient status hyperlipidemia not controlled, ref SDS 49 PSXT; Doctor
601018 - Egan makes referral to SF VA Medical Center for consult on
601019 - participation clinical trials, ref SDS 49 EU9F, with experimental
601020 - agents such as AMGEN 145 and REGN 727 to resolve multiple statin
601021 - intolerance. ref SDS 49 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 50 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 51 0001, and
601033 - further raise the LDL 70 to LDL 190, as a target for cardiovascular
601034 - risk. ref SDS 51 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 52 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 53 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 55 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 57 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 58 GH5M
601065 - ..
601066 - On 131216 0028 letter to Doctor Alba submit agenda for meeting at VA
601067 - SFMC on 131219. ref SDS 59 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 60 NJ6G
601075 - ..
601076 - On 131230 1450, received Ezetimibe in US mail, ref SDS 61 5N3O,
601077 - ordered by Doctor Alba on 131219, 131219 0930, ref SDS 60 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 53 6H6K
601081 - ..
601082 - On 140114 0845 letter to Diana request Progress Notes meeting 131219,
601083 - ref SDS 62 HY6O, and ask about expanding scope pending lab to include
601084 - LDL-P. ref SDS 62 2140
601086 - ..
601087 - On 140115 1842 letter Diana will look for Progress Notes meeting
601088 - 131219, ref SDS 63 HY6O; investigating prospects for ordering lab test
601089 - LDL-P, ref SDS 63 CE80; VA claims patient cholesterol and LDL are above
601090 - target. ref SDS 63 CE91 VA further claims testing LDL-P not effective
601091 - in this case because LDL-C is not optimal. ref SDS 63 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 64 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 64 735Y
601100 - ..
601101 - On 140128 1327 letter asks again about Progress Notes meeting 131219,
601102 - ref SDS 65 HY6O; report hiking 11 miles per day continued, weight hit
601103 - 165, ref SDS 65 TZ8U; ask where to get lab at VA Martinez, in San
601104 - Francisco, or at UCSF. ref SDS 65 TZ96 No side effects from
601105 - Atorvastatin and Ezetimibe. ref SDS 65 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 66 OO5G lab blood draw at
601110 - Labcorp in Walnut Creek on Ygnacio Valley Road. ref SDS 66 NT6T
601112 - ..
601113 - On 140201 1159 obtained blood draw for Lipid NMR test at Labcorp on
601114 - Health Testing Centers order # 27716, ref SDS 67 KQ4L, showing
601115 - "concordance" LDL-P 861, LDL-C 81, HDL 61, TG 68, LDL (pattern A) size
601116 - = large buoyant protective. ref SDS 67 IM9N
601118 - ..
601119 - On 140203 1147 VA blood draw at Martinez clinic to cross check Labcorp
601120 - blood test. 140203 1147, ref SDS 68 KK9M, showing LDL-C 93, HDL 58, TG
601121 - 47, ref SDS 68 IM9N, indicating "concordance" LDL-P 626, LDL (pattern
601122 - A) size = large buoyant protective. ref SDS 68 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 69 HY6O Cause for 6-weeks delay
601128 - issuing Progress Notes not clear in the record. ref SDS 69 V44F VA
601129 - Progress Notes for meeting on 131219, are comprehensive and helpful.
601130 - ref SDS 69 MR3G Progress Notes have many minor grammatical errors
601131 - likely due to limited time, ref SDS 69 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 69 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 69
601138 - 6U4L VA concurs that lowering weight toward BMI standards aids
601139 - resolving hyperlipidemia. ref SDS 69 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 69 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 69 HU5M
601145 - VA prefers patient get labs drawn at San Francisco VA Medical Center.
601146 - ref SDS 69 PT3M
601148 - ..
601149 - On 140211 0133 letter submits agenda to VA for meeting scheduled on
601150 - 140213. ref SDS 70 HY6O Progress Notes on 131219 received from VA on
601151 - 140204 1236. ref SDS 69 HY6O, stating LDL-P provides stronger
601152 - association with CVD risk, ref SDS 60 GO35, and VA letter saying
601153 - patient can support the team with NMR lab, reported on 140204 1236.
601154 - ref SDS 69 CE80, was implemented on February 1 using Labcorp. VA
601155 - request to have lab at San Francisco reported on 140204 1236.
601156 - ref SDS 69 PT3M, was received the day after lab was drawn at Martinez.
601157 - Will do VA labs in San Francisco for next cycle. ref SDS 70 TU68
601159 - ..
601160 - On 140211 0133 letter notifies VA consolidated patient history shows
601161 - strong alignment, ref SDS 70 TV31, between NMR test on 140201, and VA
601162 - lipid panel 2 days later on 140203. ref SDS 68 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 68 5C7M,
601165 - aligns with Labcorp results. ref SDS 70 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 57 FI3G, and submitted to the VA in a
601170 - letter on 140116 0814, ref SDS 64 H29T; and previously cited in a
601171 - prior letter on 140114 0845, ref SDS 62 2140, patient healthy and very
601172 - grateful for outstanding care by entire VA team. ref SDS 70 TV3M
601174 - ..
601175 - On 140211 0133 letter notifies VA lab on 140203 improving prior lab on
601176 - 131015, ref SDS 70 TV40, resulted from Atorvastatin 40 mg - 4 weeks
601177 - beginning on 131121, shown in case study on 120101 0900, ref SDS 20
601178 - RN3F, then Atorvastatin 10 mg and Ezetimibe 10 mg beginning on 131230,
601179 - also in case study, ref SDS 20 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 68 I17G
601185 - ..
601186 - On 140211 0133 letter notifies VA lab on 140203 shows potassium (K 5.4)
601187 - is elevated again, ref SDS 70 TV5F, and T Bilirubin 2.1 further
601188 - increased again, while Labcorp shows these are stable. ref SDS 68 ZG5O
601190 - ..
601191 - On 140213 0830 meeting at VA Medical Center in San Francisco
601192 - ref SDS 71 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 71 TB6J Medical team excellent results collaborating
601195 - doctor/patient partnership. ref SDS 71 1L7M Atorvastatin 40 mg
601196 - started 131121, and then changed to Atorvastatin 10 mg with Ezetimibe
601197 - 10 mg started 131230. ref SDS 71 IE7F No side effects taking
601198 - medication. ref SDS 71 333L Discordance between LDL-P and LDL-C
601199 - discussed. ref SDS 71 WM8J Continue medication, diet, exercise and
601200 - weight loss protocols, and test lipid panel again in 3 months on
601201 - 140519 0800. ref SDS 71 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 71 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 71 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 71 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 71 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 71 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 68 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 68 BE6O, and is
601228 - otherwise not supported by reference to recognized authority.
601229 - ref SDS 71 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 71 E34O
601236 - ..
601237 - On 140226 1332 letter to VA transmits notes of meeting on 140213.
601238 - ref SDS 72 HY6O Report cold symptoms side effects taking Atorvastatin
601239 - with Ezetimibe. ref SDS 72 JY8K Request coronary CTA radiology test
601240 - regression atherosclerosis. ref SDS 72 JR99 Request Progress Notes
601241 - meeting on 140213. ref SDS 72 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 73 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 73 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 74 WY3X, since CABG x4 surgery on 091022
601256 - 0700. ref SDS 6 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 75 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 75 MS9N
601268 - ..
601269 - On 140308 0956 another letter asking VA to investigate delayed
601270 - delivery medication refills. ref SDS 76 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 77 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 77 VP4J At 1156
601278 - notified VA have not received medication. ref SDS 77 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 78 YS4O At 1903 notified VA
601284 - medication refill was received, so treatment resumed. ref SDS 78 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 79 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 79 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 79 IL4M, cited in VA Progress Notes
601297 - on 131219, ref SDS 60 GO35, and restated in Progress Notes for meeting
601298 - on 140213 0830. ref SDS 71 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 57
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 79
601312 - PSXX, discussed during the meeting on 140213 0830, ref SDS 71 JZ4O,
601313 - citing research on 131125 0005. ref SDS 57 E13K.
601315 - ..
601316 - On 140430 0900 at 0400 letter to Doctor Egan Cardiology VA Clinic
601317 - Martinez agenda for meeting 0900, ref SDS 80 HY6O, report patient
601318 - history of lipid labs, ref SDS 80 PT53, may show discordance with
601319 - LDL-P low and LDL-C high, indicating low risk CVD. ref SDS 80 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 80 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 80 2F6O, that required CABG +4 on
601332 - 091022 0700, ref SDS 6 PQWU, as considered previously with the VA
601333 - during the meeting in San Francisco on 140213 0830, ref SDS 71 JZ4O,
601334 - and cited in the letter on 140312 1720. ref SDS 79 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 80 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 80 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 80 RI9N The doctor asked about resting heart rate,
601352 - ref SDS 80 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 20 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 80 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 80 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 80 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 81 YV4L, shown in labs reported in
601374 - the record on 140203 1147. ref SDS 68 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 82 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 82 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 82 BE6O Improved lipid history, ref SDS 82 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 82 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 83 X45G Excellent lipid
601394 - lab, ref SDS 83 IM9N, aligns with Labcorp blood test using NMR
601395 - technology last week on 140508 1133. ref SDS 82 5C7M Reflects
601396 - increased hiking and weight control past 3.5 months, reported in case
601397 - study on 120101 0900, ref SDS 20 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 20 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 83 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 84 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 84 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 80 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 84 YM82, see case study (see line 105253
601420 - shown on 120101 0900. ref SDS 20 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 84 YM98
601430 - ..
601431 - On 140515 2043 letter to VA requests coronary CTA with calcium score
601432 - to evaluate regression of atherosclerosis. ref SDS 84 YM41 Further
601433 - requests EPC lab to assess favorable conditions along with elevated
601434 - HDL for regression of atherosclerosis. ref SDS 84 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 83 W25L Thanks to skill and persistence of the VA medical
601443 - team, this time the numbers improved. ref SDS 84 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 85
601448 - 1V6M Medication side effects of dizziness seems to have subsided.
601449 - ref SDS 85 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 85 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 85 DV59
601457 - ..
601458 - On 140519 0800 meeting at VA Doctor Alba ordered another lab to test
601459 - potassium and other electrolytes. ref SDS 86 HY6O Doctor pleased
601460 - patient implemented prescribed care to continue physical activity that
601461 - yielded favorable lipid labs to lower CVD risk. ref SDS 86 X59G
601462 - Hiking 300 miles per month lowered weight, lowered triglycerides and
601463 - increased HDL 67, also aided with orange juice. ref SDS 86 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 86 IW6L VA concerned anatomy changes from CABG surgery 5
601468 - years ago makes CTA difficult. ref SDS 86 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 86 OF7N Medication with
601471 - Atorvastatin 10 mg and Ezetimibe 10 mg and hiking 300 miles per month
601472 - cause adverse side effects. ref SDS 86 PC8K Doctor Alba explained
601473 - patients must tolerate adverse side effects in order to benefit from
601474 - line of care. ref SDS 86 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 86 635O
601479 - ..
601480 - On 141230 0909 called VA and scheduled meeting with Doctor Rao on
601481 - 150213 0830. ref SDS A2 PQ6J
601482 -
601483 -
601484 -
601485 -
601487 - ..
6015 -
6016 -
6017 - Progress
6018 -
601801 - Lab Electrolytes Cross Check Potassium T Bili Doctor Egan Request
601802 - Potassium T Bili Lab Cross Check Electrolytes Request Doctor Egan
601803 -
601804 - Follow up ref SDS A1 HY6O, ref SDS 86 HY6O.
601805 -
601806 - The meeting today was scheduled on 141230, ref SDS A2 PQ6J, to follow
601807 - up prior patient encounter on 141024 0900. ref SDS A1 HY6O
601809 - ..
601810 - Doctor Rao was pleased with LDL-P 709 in the NMR lipid lab on 150208,
601811 - as shown on 150209 1012. ref SDS A3 U45J
601813 - ..
601814 - The doctor cited improved HDL 70, increased from HDL 30 reported 5
601815 - years ago when patient required CABG x4 surgery on 091022. She
601816 - explained that HDL 70 provides significant protection against CVD,
601817 - resulting from treatment hiking 10,000 miles the past 4 years.
601819 - ..
601820 - Discussed ordering CCTA to evaluate reducing statin treatments based
601821 - on expected findings of regressed atheosclerotic plaques, which would
601822 - enable recovery from dehydration caused by frequent urination from
601823 - taking statin medication. This follows up prior discussions on
601824 - ordering CCAT during prior meeting on 141024 0900. ref SDS A1 WU8J
601826 - ..
601827 - The doctor left the examination room briefly to confer with Doctor
601828 - Feingold, attending. On returning, Doctor Rao seemed to say that HDL
601829 - 70 having more than doubled, cannot be further increased.
601831 - ..
601832 - The doctor continued to present prior objections to ordering CCTA on
601833 - grounds that patients cannot recover from atherosclerosis. Therefore,
601834 - the only course of treatment is to slow the advance of CAD by lowering
601835 - LDL-C with statin treatments. Doctor Rao related results from meeting
601836 - with Radiology staff following prior meeting with patient on 141024.
601837 - She feels this investigation indicated CCTA cannot effectively
601838 - evaluate severity of athorsclerosis for the purposes of guiding dose
601839 - levels of statin medications, such that favorable CCTA results justify
601840 - lowering statin drugs that would reduce liver damage causing
601841 - dehydration with consequent severe feet injuries that prevent hiking
601842 - needed to maintain HDL levels that regress atherosclerosis.
601844 - ..
601845 - Actually, Doctor Rao filed an addendum for Progress Notes for prior
601846 - meeting with patient on 141024, which says...
601847 -
601848 - Addendum (10/28/14): As per Mr.Welch's request, I talked to our
601849 - radiologist here at the VA regarding technical limitations of
601850 - doing a CTA in patients with prior CABG. Radiologist (Dr.Matt
601851 - Barkovich) informed me that, while a CAC score could be obtained,
601852 - it would not be accurate because the venous grafts in place after
601853 - CABG are in different planes, and these are not accounted for in
601854 - the planes that are set up for reading. 141024 0900, ref SDS A1
601855 - 1S4L
601856 -
601858 - ..
601859 - [On 150729 0800 Doctor Rao reluctant to order CCTA to
601860 - evaluate response to treatment raising HDL 30 to HDL 70,
601861 - 130% over past 4 years; will make referral to Cardiology
601862 - for considering CCTA in this case. ref SDS A5 TA91
601864 - ..
601865 - [On 151014, Doctor Simpson ordered CCTA radiology study, as
601866 - an experiment for cardiology. ref SDS A6 OG3N
601868 - ..
601869 - [On 151019 0930 CCTA with calcium score performed; meeting
601870 - with doctor in Radiology Department reviewed requirements
601871 - for calcium score to evaluate response to treatment
601872 - recovering from atherosclorosis. ref SDS A7 GR4K At the
601873 - end of the meeting, the doctor agreed to perform calcium
601874 - score for comprehensive CCTA test. ref SDS A7 LQ5F
601875 - However, analyst's report merely says "All the bypass
601876 - grafts are patent." ref SDS A7 JW8O
601878 - ..
601879 - [On 151203 1014 meeting with Doctor Elicker in Radiology
601880 - Department seemed to clarify that he read the CCTA scan
601881 - file performed on 151019, and found no evidence of lesions
601882 - nor stenosis blockages of any amount anywhere in the active
601883 - circulatory system which was covered by the scan.
601884 - ref SDS A9 SZ5F
601886 - ..
601887 - [On 160104 0855 Doctor Jha, attending physician for this
601888 - CCTA imaging study, advised that standard of practice for
601889 - radiology reporting is to present any and all blockages of
601890 - any kind observable in CCTA scan imaging; so, in this case,
601891 - since none are reported, the CCTA test on 151019, can
601892 - correctely be interpretted to mean there are no blockages,
601893 - plaques, stenosis of any kind evident from the scan file
601894 - record. ref SDS B0 054G
601896 - ..
601897 - [On 160114 0022 letter commends Doctor Jha and faculty
601898 - colleagues at UCSF for good faith review to clarify CCTA on
601899 - 151019, that demonstrates CCTA evaluating response to
601900 - treatment (hiking 10K miles raising HDL 30 to 70) for
601901 - regressing atherosclerosis to 0. ref SDS B1 N760
601903 - ..
601904 - [On 160203 1000 Doctor Simpson pleased hiking 240 miles
601905 - prior 3 weeks caused patient HDL 73 improved HDL 70
601906 - achieved last year; TG 61 resulted in TG/HDL ratio < 1, and
601907 - LDL-P 699 with LDL particle size 20.9 (large that resists
601908 - penetration of endothelial lining of blood vessels),
601909 - ref SDS B4 NV5I, shown in blood tests, reported in another
601910 - record on 160202 1220. ref SDS B3 BE6O
601912 - ..
601913 - [On 160203 1000 Doctor Simpson reduced statin treatments
601914 - 50% based on CCTA findings on 151019, and in order to
601915 - reduce side effects that cause dehydration, so that hiking
601916 - can remain at levels that raise HDL to a level that
601917 - regresses atherosclerosis. ref SDS B4 UV5M
601918 -
601919 -
601920 -
601921 -
601922 -
601923 -
601924 -
601925 -
601926 -
601927 -
601928 -
601929 -
601930 -
601931 -
601932 -
601933 -
601934 -
6020 -
SUBJECTS
Default Null Subject Account for Blank Record
6103 -
610401 - ..
610402 - Medical Chart Progress Notes Meeting 140519 VA SF Medical Center
610403 -
610404 - Follow up ref SDS A1 476K, ref SDS 86 476K.
610405 -
610406 - VA Progress Notes for meeting on 150213 are stored in...
610407 -
610418 - ..
610419 - 1. LOCAL TITLE: ENDOCRINE ATTENDING PROGRESS NOTE (MED)
610420 - STANDARD TITLE: ENDOCRINOLOGY ATTENDING NOTE
610421 - DATE OF NOTE: FEB 13, 2015@18:10
610422 - ENTRY DATE: FEB 13, 2015@18:10:53
610424 - EXP COSIGNER:
610425 - URGENCY:
610426 - STATUS: COMPLETED
610428 - ..
610429 - 2. HPI
610430 -
610431 - 1. 69 year old male with CAD (s/p CABG 2009) and achalasia,
610432 - here for f/u of hyperlipidemia. Pt last seen in endocrine
610433 - clinic 4 mths ago (10/2014); please see my note dated
610434 - 10/24/2014 for details of patients medical history.
610435 - ref SDS A1 KD8M
610437 - ..
610438 - 2. Pt is currently taking atorvastatin 10 mg qd and zetia 10
610439 - mg qd and is tolerating these well.
610441 - ..
610442 - 3. Since his last visit, pt states he has been doing.
610444 - ..
610445 - 4. He continues to hike daily for significant amounts; his
610446 - foot pain due to the hiking have improved with the help of
610447 - podiatry.
610449 - ..
610450 - 5. Other issues discussed today include:
610451 -
610452 - 1. Pt would like to decrease rx doses (as he has stated
610453 - in the past).
610454 -
610455 - [On 160203 1000 Doctor Simpson reduced treatment
610456 - with statns (Atorvastatin 10 mg and Ezetimibe 10 mg)
610457 - by 50%, ref SDS B4 UV5M, based on favorable CCTA on
610458 - 151019 showing regression of atherosclerosis plaques
610459 - to calcium score 0 in active circulatory system,
610460 - ref SDS A7 SU62, and blood test showing lab results
610461 - HDL 73 on 160131. ref SDS B2 BE6O
610463 - ..
610464 - 2. Laboratory values from chem 10 and lipid panel.
610466 - ..
610467 - 3. Diet over past few months; we reviewed pt's online blog
610468 - together, which details his food intake on a daily
610469 - basis. We reviewed 2 separate 1-week periods. During
610470 - each of those days, pt had a portion of foods that was
610471 - high in saturated fats; this includes either 1/2
610472 - burger+fries, steak salad, bacon+eggs, or steak+pie+ice
610473 - cream. Of note, pt did point out that his portion sizes
610474 - were quite small (for example, he eats 1/2 burger,
610475 - never a full one).
610477 - ..
610478 - 4. Pt's weight has decreased by almost 10 lbs over past 4
610479 - mths (197-->187).
610480 -
610482 - ..
610483 - PMH/PSH:
610484 -
610485 -
610486 -
610487 -
610488 -
610489 -
610490 -
610491 -
610492 -
610493 -
610494 -
610495 -
610496 -
610497 -
610498 -
610499 -
610500 -
610501 -
610502 -
610503 -
610504 -
610505 -
610506 -
610507 -
610508 -
610509 -
610510 -
610511 -
6106 -