CONTACTS
SUBJECTS
Meeting Schedule 150729 0830 Evaluate Medication Atorvastatin Ezetim
1703 -
1703 - ..
1704 - Summary/Objective
1705 -
170501 - Follow up ref SDS 58 0000. ref SDS 57 0000.
170502 -
170503 -
170504 -
170505 -
170506 -
170507 -
170509 - ..
1706 -
1707 -
1708 - Background
1709 -
170901 - On 150519 1000 Connie called and said Doctor Sandhu cannot meet
170902 - because he is attending a funeral, i.e., a death in the family.
170903 - Meeting rescheduled again to 150721 0930.
170905 - ..
170906 - On 150522 0848 Connie called and said Doctor Sandhu has to cancel the
170907 - meeting on 150721, scheduled on 150419. The doctor now has an opening
170908 - on 150618 1130. She asked if this will work? Agreed to meet on
170909 - 150618 1130. ref SDS 52 H16J
170911 - ..
170912 - On 150606, checked VA meetings scheduled on the VA Internet system...
170922 - ..
170923 - It said the meeting with Doctor Sandhu on 150618 1130 is cancelled,
170924 - shown on 150606 1023. ref SDS 54 6P6G
170926 - ..
170927 - On 150608 0443 at 1306 received letter from Doctor Rao planning to
170928 - schedule meeting with her in MPA clinic. ref SDS 56 F95N
170930 - ..
170931 - On 150615, Connie in Primary called and confirmed meeting with Doctor
170932 - Sandhu on 150618 has been cancelled. She proposed earliest meeting
170933 - with the doctor can be scheduled is in August. Connie said she will
170934 - send a notice in July of date and time for meeting in August with
170935 - Doctor Sandhu.
170937 - ..
170938 - On 150616, received call from VA scheduling meeting with Doctor Rao in
170939 - Medical Practice (Primary Care) on 150729 0800. ref SDS 58 FO9I
170940 -
170941 -
170943 - ..
1710 -
1711 -
1712 - Progress
1713 -
171301 - Previously, met with Doctor Rao in the Endocrinology and Metabolic
171302 - Syndrom Clinic at the VA Medical Center in San Francisco, and at that
171303 - time the doctor was pleased LDL-P 709 was well below established
171304 - metrics for low risk of CVD, and further HDL 70 was 130% higher than
171305 - when patient was diagnozed with CAD 6 years ago, and further is well
171306 - above criteria required to regress atherosclerotic plaques, reported
171307 - on 150213 0830. ref SDS 47 HY6O
171309 - ..
171310 - Doctor Rao received the letter submitting the agenda for the meeting
171311 - today, and sent late yesterday on 150728 2247. ref SDS 62 VY6H
171313 - ..
171314 - During the meeting today, Confirmed understandings that Doctor Rao
171315 - will continue managing Atorvastatin Ezetimibe protocol, after moving
171316 - from Endocrinology to now work in Medical Practice providing Primary
171317 - Care.
171319 - ..
171320 - Initially, reported mild injury to right knee, possible MCL injury
171321 - from twisting the ankle. On 150326, during regular 11 mile hike had
171322 - to run across Ygnacio Valley Road to miss traffic during rush hour at
171323 - 0730. It was still dark so missed seeing uneven surface that then
171324 - twisted the ankle, reported in case study on 140101 0600. ref SDS 29
171325 - 6O6F The next day on 150327 0728 research indicated may have strained
171326 - MCL on right knee. ref SDS 49 K05I
171328 - ..
171329 - Over the next several weeks tried a few hikes, but injury took
171330 - longer to heal. On 150414, resumed normal hiking. ref SDS 29 R65L On
171331 - 150417, right knee seems loose, pops more often now. ref SDS 29 UP9H
171332 - On 150423, right knee MCL injury felt much better entire 11 mile hike.
171333 - Afterward, no more pain laying down in bed. ref SDS 29 AW8O
171335 - ..
171336 - Doctor Rao was pleased to hear today, that on 150425, 4 weeks after
171337 - right knee MCL injury on 150326, the injury seemed entirely recovered,
171338 - in that the patient resumed normal hiking 11 miles per day, shown in
171339 - case study on 140101 0600. ref SDS 29 YG5O
171341 - ..
171342 - Doctor Rao said that knee injuries take time to fully recover. The
171343 - level of stress both knees suffer hiking 11 miles per day, could cause
171344 - recurrence of injury to right knee. She said if pain returns to right
171345 - knee, she will order an MRI to aid diagnosis and prescription of care.
171346 -
171347 - [On 151215 1000 Podiatry Biomechanics modified 1 of 2 pair
171348 - orthotic inserts, tilting feet causing pressure on knees.
171349 - ref SDS 64 9B6I This additional pressure on the knees
171350 - thereafter occurred every other day, since the 2 pair of
171351 - inserts are rotated between 5 pair of Hoka Stinson Lite
171352 - shoes for 11-mile hikes every day. ref SDS 64 1J9G
171354 - ..
171355 - [On 160202 1540 reported injury to right knee, very painful
171356 - since changes to orthotic inserts on 151215, ref SDS 65
171357 - WG59; Doctor Tang recommended not using adjusted orthotic
171358 - inserts, until meeting with Doctor Hewitson in Podiatry
171359 - Biomechanics can evaluate adjustments to avoid right knee
171360 - injury. ref SDS 65 NL3O
171362 - ..
171363 - Doctor Rao asked about the left knee?
171365 - ..
171366 - Explained left knee has had continuing pain from serious industrial
171367 - accident 40 years ago that required removing cartalege. This caused
171368 - chronic degenerative arthritis in the left knee. Fortunately, this
171369 - pain is well managed taking Glucosamine Chondroitin liquid before
171370 - going on hikes. Even on 11-mile hikes every day, there is no pain in
171371 - the left knee, unless on occasion forget to medicate with Glucosamine
171372 - Chondroitin. This solution, however, has no effect on right knee
171373 - after the injury on 150326. Only a month's rest provided full relief.
171375 - ..
171376 - The doctor asked about feet injuries that prevent daily hiking,
171377 - presented in the letter yesterday, referencing discussion with Doctor
171378 - Tang in Podiatry, reported on 150728 2247? ref SDS 62 W894
171380 - ..
171381 - Doctor Rao asked to remove shoes and socks to examine dehydration of
171382 - feet, requested by Doctor Tang cited in the letter yesterday on 150728
171383 - 2247. ref SDS 62 W894 Asked Doctor Rao to report in Progress Notes
171384 - observing today, severe dehydration causing cracking, peeling,
171385 - bleeding soles of both feet, side effects taking Atorvastatin 10 mg
171386 - with Ezetimibe statin medications the past 18 months.
171387 -
171388 - [...below on 150729 0800 Progress Notes do not report
171389 - severe dehydration caused by Atorvastatin Ezetimibe
171390 - medications causing frequent urination; presents finding
171391 - only calluses, ref SDS 0 299K, and saying f/b Podiatry,
171392 - defer to Doctor Tang. ref SDS 0 XZ3L
171394 - ..
171395 - Doctor Rao was none-the-less pleased LDL-C is the lowest in patient
171396 - history, having declined from 200+ over the past 18 months to below
171397 - 90.
171399 - ..
171400 - Doctor Rao also noted that HDL 65 continues very favorably above
171401 - established metrics for regressing atherosclerotic plaques. She feels
171402 - extended endurance exercise hiking 11 miles per day, over several
171403 - years has raised HDL 30 at the time of CABG x4 surgery on 091022 0700,
171404 - ref SDS 3 PQWU, to HDL 70 reported in lab at VA on 150209 1012.
171405 - ref SDS 46 5C7M Even though HDL 65 on recent lab is very favorable,
171406 - the drop from HDL 70, just 6 months ago, aligns with reduced hiking
171407 - due to right knee injury in late March, per above. ref SDS 0 UE9O
171408 - Currently, feet injuries hamper hiking, also above. ref SDS 0 DU5M
171410 - ..
171411 - Doctor Rao will make referral to Doctor Tang in Podiatry for
171412 - resolving feeting injuries in order to maintain level of hiking that
171413 - has yielded significant benefits raising HDL 130%.
171415 - ..
171416 - Doctor Rao remains reluctant to order CCTA, discussed during the prior
171417 - meeting on 150213, and set out in the agenda for the meeting today, in
171418 - the letter yesterday on 150728 2247. ref SDS 62 W84X During the
171419 - meeting today, the doctor used the computer in the examination room to
171420 - open Doctor Stewart's Progress Notes for the meeting on 150623. She
171421 - found that Doctor Stewart refers CCTA to Primary. ref SDS 60 UM4O
171423 - ..
171424 - Doctor Rao pointed out that Progress Notes for the meeting on 150623,
171425 - do not say why Doctor Stewart supports CCTA test; and that she
171426 - therefore feels there are insufficient grounds for Primary Care to
171427 - order CCTA, which is strongly opposed by Endocrinology reported on
171428 - 140519 0800. ref SDS 31 J83H
171430 - ..
171431 - The doctor's concern aligns with the letter to Doctor Stewart
171432 - requesting supplemental addendum that presents reasons for ordering
171433 - CCTA to evaluate regression of atherosclerosis that indicates
171434 - opportunity to reduce statin drugs in order to reduce side effects,
171435 - reported on 150701 1057. ref SDS 61 NU8L
171437 - ..
171438 - Doctor Rao advised that this state of the record indicates ordering
171439 - CCTA should be referred to Cardiology.
171441 - ..
171442 - We considered contacting Doctor Paulson [...later determined to be
171443 - Doctor Simpson...] in Cardiology, based on recommendation that this
171444 - doctor has a strong background in cardiology research, which may be
171445 - open to favorable consideration ordering CCTA to evaluate research on
171446 - 131125, that indicates HDL and EPC blood elements can be elevated
171447 - through extended endurance exercise, that this condition can rapidly
171448 - regress atherosclerosis, and that over the past several years, the
171449 - patient in this case has performed daily extended endurance exercise
171450 - hiking 11 miles per day, 300 miles per month.
171452 - ..
171453 - Doctor Rao looked for Paulson and Sampson in the VA Medical Center
171454 - personnel listing, but could not find anyone with that name.
171456 - ..
171457 - Advised will investigate further and submit the name of the doctor in
171458 - Cardiology who may be able to support ordering CCTA.
171459 -
171460 -
171461 -
171462 -
171464 - ..
1715 -
1716 -
1717 - 0921
1718 -
171801 - After meeting with Doctor Rao in Building 200 1st floor Primary Care
171802 - (also "Medical Practice"), walked across the street to building 203 on
171803 - the 2nd floor and visited Cardiology administration offices, where
171804 - Karen had previously suggested a contact. Karen is out of the office
171805 - today. Her colleague gave the name of the contact, Doctor Paul
171806 - Simpson, which Karen submitted previously during a meeting on 150526
171807 - 1148. ref SDS 53 PB70
171808 -
171809 - [On 150730 0952 letter to Doctor Rao submits contact in
171810 - Cardiology, Doctor Simpson, for referral who might support
171811 - ordering CCTA. ref SDS 63 UR45
171812 -
171813 -
1719 -
SUBJECTS
Default Null Subject Account for Blank Record
1803 -
180401 - ..
180402 - Medical Chart Progress Notes Meeting 140519 VA SF Medical Center
180403 -
180404 - Follow up ref SDS 47 476K, ref SDS 43 476K, ref SDS 31 476K.
180405 -
180406 - VA Progress Notes for meeting on 150213 are stored in...
180408 - ..
180409 - F:\05\00003\SM\CC\AGMJ\20150729-083938\W0144.pdf
180411 - ..
180412 - F:\05\00003\SM\CC\AGMJ\20150729-083938\W0144.pdf
180414 - ..
180415 - F:\05\00003\SM\CC\AGMJ\20150729-083938\W0144.pdf
180417 - ..
180418 - LOCAL TITLE: MP INITIAL VISIT NOTE (MED/NURSING/CLINIC)
180419 - STANDARD TITLE: PRIMARY CARE OUTPATIENT INITIAL EVALUATION NOTE
180420 - DATE OF NOTE: JUL 29, 2015@08:39 ENTRY DATE: JUL 29, 2015@08:39:38
180421 - AUTHOR: RAO,MADHU EXP COSIGNER:
180422 - URGENCY: STATUS: COMPLETED
180424 - ..
180425 - ID: 69 year old male with CAD (s/p CABG 2009), HLD and
180426 - achalasia, who is well known to me from endocrine clinic, here
180427 - to establish primary care. Pt previously seen in Martinez VA.
180428 - Issues discussed today are:
180429 -
180430 - 1. Feet calluses (bilat hallux, lt>rt)-- f/b podiatry, and had
180431 - debridement on 6/2015. Pt concerned that callus on left foot
180432 - will not resolve; he has been using creams prescribed by
180433 - podiatry without much effect.
180435 - ..
180436 - Progress Notes citing "debridement on 6/2015" references meeting with
180437 - Doctor Tang on 150619 0840. ref SDS 59 CO44
180439 - ..
180440 - Doctor Rao report of "feet calluses" seems too brief summary of severe
180441 - cracking, peeling, bleeding observed during the meeting today, and
180442 - without association with statin medications causing dehydration from
180443 - frequent urination, per examination during meeting today, shown above.
180444 - ref SDS 0 TA8L
180446 - ..
180447 - Progress Notes continue...
180448 -
180449 - 2. Rt knee pain -- Had sprain in 3/2015, improved over the
180450 - subsequent month, but pt still has mild discomfort after
180451 - hiking; no give way weakness, no clicks/pops, no problems
180452 - withou suddent rotational movements. He has also developed
180453 - mild discomfort after long hikes in the left knee (on which
180454 - he had surgery years ago).
180456 - ..
180457 - Doctor Rao presents report on injury to right knee, discussed during
180458 - the meeting today, per above. ref SDS 0 UE9O
180460 - ..
180461 - Progress Notes continue...
180462 -
180463 - 3. CAD & HL --Pt on atorvastatin 10 mg qd and zetia 10 mg qd
180464 - and is tolerating these well; continues tohike sig amounts.
180465 - He continues to request a cardiac CTA for evaluation of
180466 - coronary vessels and for determination of improvement in
180467 - atherosclerotic plaques--would like to use CAC score to
180468 - follow plaque burden and to decrease intensity of drug
180469 - treatment. Pt also states that there is now an additional
180470 - reason to obtain CTA--states that fundoplication may be
180471 - loosening (see Gen Surg notes on 6/24/15 for details), and
180472 - his omeprazole dose has been increased to 40 bid. BUT, pt
180473 - reluctant to take higher dose due to the possible risks on
180474 - CAD--pt quotes a paper that he recently read. He will send
180475 - me the reference for me to review. Of note, we did not
180476 - have time today to review his food log, which has been an
180477 - issue in the past.
180479 - ..
180480 - ROS: otherwise, pt is doing well, feels well.
180482 - ..
180483 - PMH/PSH:
180484 - 1. Esophageal Achalasia - s/p lap heller myotomy and
180485 - fundoplication 12/2009
180486 - - s/p EGD with dilations
180487 - 2. CAD s/p CABG x4 in 2009
180488 - 3. GERD
180489 - 4. Hyperlipidemia
180490 - 5. left knee repair
180492 - ..
180493 - MEDICATIONS:
180494 - Omeprazole 40 mg BID
180495 - Atorvastatin 10 mg po daily
180496 - Zetia 10 mg po daily
180498 - ..
180499 - PHYSICAL EXAM
180500 - Height: 66 in [167.6 cm] (07/29/2015 08:12)
180501 - Weight: 189.6 lb [86.2 kg] (07/29/2015 08:12)
180502 - Pulse: 69 (07/29/2015 08:12)
180504 - ..
180505 - Temp: 97.9 F [36.6 C] (07/29/2015 08:12)
180506 - B/P: 137/74 (07/29/2015 08:12)
180507 - O2 Sat: 7/29/15 08:12:46 O298
180508 - Gen=pleasant, comfortable male, NAD
180509 - HEENT=NCAT, op clear, anicteric
180510 - ext: bilat feet with thickened, hypertrophic toenails.
180511 - Left foot with thickened callus on medial aspect of
180512 - D1. Rt foot with very small callus
180514 - ..
180515 - LABS: 7/28/14: CBC WNL
180516 - Test name Result units Ref. range Site Code
180517 - EGFR 72 mL/min Ref: >=60 [662]
180518 - SODIUM 142 mmol/L 135 - 145 [662]
180519 - POTASSIUM 4.4 mmol/L 3.3 - 4.8 [662]
180520 - CHLORIDE 104 mmol/L 101 - 112 [662]
180521 - CARBON DIOXIDE 31 mmol/L 24 - 32 [662]
180522 - ANION GAP 7 mmol/L 5 - 20 [662]
180523 - UREA NITROGEN 22 mg/dL 10 - 24 [662]
180524 - CREATININE 1.02 mg/dL 0.6 - 1.3 [662]
180525 - GLUCOSE 110 mg/dl 65 - 115 [662]
180526 - CALCIUM 9.2 mg/dL 8.5 - 10.5 [662]
180527 - PHOSPHORUS 2.9 mg/dL 2.5 - 4.5 [662]
180528 - ALBUMIN 4.2 gm/dL 3.3 - 5.2 [662]
180529 - CHOLESTEROL 153 mg/dl 100 - 240 [662]
180530 - TRIGLYCERIDE 54 mg/dl 10 - 190 [662]
180531 - HDL 65 mg/dl Ref: >=35 [662]
180532 - LDL (Calculated) 78 mg/dl Ref: <=131 [662]
180534 - ..
180535 - Oct 21 2014 TC 159 LDL 90 HDL 57 TG 65
180536 - May 8 2014 TC 162 LDL 83 HDL 67 TG 59
180537 - Feb 3rd 2014 TC 160 LDL 93 HDL 58 TG 47 HgA1c 5.5%
180538 - Labcorp TC 156 LDL 81 HDL 61 TG 61
180539 - October 2013 TC 321 LDL 249 HLD 50 TG 85 TBil 1.7 Hga1c 5.5% CPK: 110 TSH 2.6
180540 - May 2013 TC 307 LDL 240 HLD 54 TG 85 TBil 1.3
180541 - November 2012 TC 173 LDL 105 HLD 57 TG 53 TBil 1.6
180543 - ..
180544 - A/P: Mr.Welch is a very pleasant, engaged 69 year old male
180545 - with CAD, achalasia and hyperlipidemia for which he is on
180546 - atorva (10 qd) and zetia (10 qd). His LDl has decreased by
180547 - >50% on the moderate dose statin + zetia, and it is almost at
180548 - goal. Furthermore, pt's HDL is extremely good at this point.
180549 - Overall, he is doing quite well.
180551 - ..
180552 - 1. Lipids - Maintain his current dose of statin+zetia as is.
180553 - Although LDL level is not exactly at goal (ie<70), it is
180554 - quite good and the HDL level is excellent, as is the TG
180555 - level.
180557 - ..
180558 - -He will continue with his hiking and wt maintenance.
180560 - ..
180561 - -We again discussed pt's request for CTA to assess
180562 - regression of atherosclerotic plaques (and if so, d/c
180563 - statin or decrease exercise). I again mentioned that CTA
180564 - is not indicated for a number of reasons, including the
180565 - fact that CTA is used clinically to determine whether pt's
180566 - have CAD, and not as a tool to modify tx regimen on an
180567 - ongoing basis. Pt also concerned about the omeprazole dose
180568 - and effects on endocthelial function as per article he
180569 - recent read; I will review the article (he said he will
180570 - send me the reference).
180572 - ..
180573 - I also offered to send him to cardiology to discuss the
180574 - issue of CTA and see whether this can be used as a
180575 - monitoring tool--pt will think about it and will send me
180576 - the name of a cardiolgist that he may be OK with seeing.
180578 - ..
180579 - --Upon review of pt's chart (after our visit), I noticed
180580 - that pt is not on ASA--not clear to me why. I called pt's
180581 - cell (415-866-7397) to try to discuss, but listed number is
180582 - no longer his. Will discuss at his next visit with me.
180584 - ..
180585 - 2. Calluses - f/b podiatry. Will defer to Dr.Tang re:tx.
180587 - ..
180588 - For some reason, Progress Notes do not report severe dehydration of
180589 - both feet observed during the meeting today, per above. ref SDS 0 TA8L
180591 - ..
180592 - Unclear if "...re.tx." makes referral to Doctor Tang, as requested by
180593 - Doctor Tang yesterday, on 150728, as reported to Doctor Rao in the
180594 - letter same day. ref SDS 62 W894
180596 - ..
180597 - Progress Notes continue...
180598 -
180599 - 3. Knee pain, rt>lt - Mild, occurs after hiking. Will
180600 - monitor. If not resolved by next visit, will order MRI
180601 - of the rt knee.
180603 - ..
180604 - This aligns with examination and review of history on right knee
180605 - injury, reported during the meeting, per above. ref SDS 0 WR6N
180607 - ..
180608 - Progress Notes continue...
180609 -
180610 - 4. RTC in 6-7 mths.
180611 -
180613 - ..
180614 - Clinical Reminder Activity
180615 - MED REC-PRIMARY CARE:
180617 - ..
180618 - Current medications reviewed with patient/caregiver and
180619 - reconciliation of medications related to today's visit
180620 - completed, including non-VA medications and discrepancies,
180621 - if identified, were addressed. Medication changes and the
180622 - importance of medication management were reviewed with the
180623 - patient/caregiver today based on individual needs.
180624 - Patient/caregiver acknowledged understanding of
180625 - instructions as stated. An updated list of reconciled
180626 - medications have been provided to the patient/caregiver.
180627 - The following is a complete list of active medications,
180628 - including non-VA meds. Patient does not have any non-VA
180629 - meds if none are listed. PSO2 - Opt Rx Profile
180631 - ..
180632 - Allergies: ROSUVASTATIN, SIMVASTATIN,
180633 - Adverse Reactions:
180634 - Active and Recently Expired Outpatient Medications (including
180635 - Supplies):
180637 - ..
180638 - Active Outpatient Medications Status
180639 -
180640 - 1. AMMONIUM LACTATE 12% LOTION APPLY LOTION TOPICALLY ACTIVE
180641 - EVERY DAY TO FEET AFTER BATHING
180642 -
180643 - 2. ATORVASTATIN CALCIUM 20MG TAB TAKE ONE-HALF TABLET ACTIVE
180644 - ORALLY AT BEDTIME FOR CHOLESTEROL
180646 - ..
180647 - 3. CLOTRIMAZOLE 1% TOP CREAM APPLY CREAM TOPICALLY TWICE ACTIVE
180648 - A DAY UNDER AFFECTED TOE
180650 - ..
180651 - 4. EZETIMIBE 10MG TAB TAKE ONE TABLET ORALLY EVERY DAY ACTIVE
180653 - ..
180654 - 5. FAMOTIDINE 20MG TAB TAKE ONE TABLET ORALLY AT BEDTIME ACTIVE
180655 - FOR STOMACH
180657 - ..
180658 - 6. UREA 20% CREAM APPLY CREAM TOPICALLY EVERY DAY TO DRY ACTIVE
180659 - CALLOUSED SKIN
180661 - ..
180662 - HDRM - REMOTE ACTIVE MEDICATIONS
180663 - Active Medications from Remote Data
180664 -
180665 - OMEPRAZOLE 40MG CAP,EC
180666 - Sig: TAKE ONE CAPSULE BY MOUTH TWICE A DAY - FOR ACID REFLUX
180667 - AND ESOPHAGEAL NARROWING. TAKE 15 TO 30 MINUTES BEFORE
180668 - A MEAL (NOTE DOSE INCREASED)
180670 - ..
180671 - Quantity: 180 Days Supply: 90
180672 - 3 refills remaining until 06/24/16
180673 - Last filled 06/24/15 at NORTHERN CALIFORNIA HCS (Active)
180675 - ..
180676 - RXNV - Non VA Meds
180677 -
180678 - No Non-VA Meds Extracted
180679 -
180680 - /es/ MADHU RAO
180681 - Staff Physician
180682 - Signed: 07/29/2015 11:03
180683 -
180684 -
180685 -
180686 -
180687 -
180688 -
180689 -
180690 -
180691 -
180692 -
180693 -
1807 -