CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 30 0000, ref SDS 29 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 - ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 090908 meeting with Doctor Lee at VA Clinic Martinez reported chest
040902 - pains hiking up first hill at Lafayette Reservoir, and which persisted
040903 - for entire lap. ref SDS 1 MY4N Previously, pain only occurred for
040904 - short distance after 1st hill, then subsided for rest of lap, and any
040905 - additional laps. Chest pain recurred 3 days in a row. Requested
040906 - Doctor Lee order EGD dilation procedure to resolve achalasia
040907 - swallowing problem, expecting this to end chest pain caused by
040908 - esophagus pressing on lungs. ref SDS 1 BU63 Doctor Lee also ordered
040909 - EKG and stress tests to assess possible coronary artery disease (CAD).
040910 - ref SDS 1 BU6W
040912 - ..
040913 - On 091002 0900 Doctor Egan, Oncology Department reports stress test
040914 - shows failure on 10 of 11 probes tested, ref SDS 2 1W5I; diagnosis
040915 - triple vessel disease - orders angiogram test to evaluate heart
040916 - problems. ref SDS 2 V86G
040918 - ..
040919 - On 091021 0716 angiogram test (cardiac catheterization) discovers
040920 - blockages in multiple cornorary arteries, ref SDS 3 7L43, schedule
040921 - heart bypass surgery on 091222. ref SDS 3 WB3K
040923 - ..
040924 - On 091021 0716 at 1429 case study VA 10+ doctors ask for patient
040925 - history achalasai and discovery of cornorary artery disease (CAD),
040926 - beginning with chest pains reported today. ref SDS 3 LJ7L
040928 - ..
040929 - On 091022 0600 CABG Progress Notes report INDICATIONS FOR SURGERY:
040930 - Patient 64-year-old man recent onset of angina. Cardiac
040931 - catheterization found extremely tight LAD lesion with TIMI II flow.
040932 - He also had multiple other lesions and severe three-vessel disease.
040933 - Referred for urgent coronary artery bypass grafting. He has normal
040934 - ventricular function. ref SDS 10 C59K Locations of 4 byass grafts was
040935 - reported. ref SDS 10 HT9G
040937 - ..
040938 - On 091022 0600 CABG Progress Notes report finding "good quality" veins
040939 - that are "good targets" for heart bypass grafts - gives confidence
040940 - there is not general widespread circulatory disease, and that
040941 - replacement grafts can hold up for a long time with good post-op diet
040942 - and exercise. ref SDS 10 YI7K
040944 - ..
040945 - On 091029 0700 patient hiking 10 laps around Telemetry ward, 3 - 6
040946 - times per day, and at all hours, e.g., 2300, 0200, 0500, 1100, 1500,
040947 - and fitted between meals, meetings, calls, tests, and rest throughout
040948 - the day. Generally averaging 3 - 4 miles per day, ref SDS 5 01F9,
040949 - Hiking is prescribed therapy to strengthen the heart and circulatory
040950 - system to recover from cardiothoracic surgery on 091022. It helps
040951 - dissipate pain and illness feeling from surgery that occur throughout
040952 - the day, reducing reliance on medications. ref SDS 5 PS7H
040954 - ..
040955 - On 091030 1742 Ultrasound results reviewed show evidence of thrombus
040956 - of right IJ vein. ref SDS 10 JL73
040958 - ..
040959 - On 091104 0718 discharged from VA recovering from quadruple heart
040960 - bypass surgery, ref SDS 6 PR4V, performed on 091022 0700. ref SDS 4
040961 - PQWU; received medical record with list of medications, also on 091104
040962 - 0718, ref SDS 6 1Q6P, and follow up meetings. ref SDS 6 9T6O
040964 - ..
040965 - On 100104 0930 meeting Primary Care VA Martinez Clinic Doctor Sandhu
040966 - indicated patient demonstrates good recovery from heart surgery on
040967 - 091022, and Heller Myotomy surgery to recover from achalasia,
040968 - performed at VA in San Francisco on 091216. ref SDS 8 PP8W
040970 - ..
040971 - On 100104 0930 medications - continue Simvastatin 20 mg 1 pill per
040972 - day, post CABG prescription ordered by Doctor Sandhu, primary care
040973 - physician. ref SDS 8 3X4L
040975 - ..
040976 - On 100721 0800 visit Doctor Sandhu Martinez VA; patient demonstrates
040977 - continuing recovery from heart surgery last October, ref SDS 9 PP8W;
040978 - patient paused Simvastatin after completing initial prescription on
040979 - 091220. ref SDS 9 3X4L Lab on 100610 shows cholesterol HDL 35, and
040980 - LDL 209 increased from 164. ref SDS 9 HY76 Doctor increased dose of
040981 - Simvestatin 40 mg. ref SDS 9 RP4F New lab ordered today shows
040982 - cholesterol reversed long-term decline and increased dramatically in
040983 - just 30 days, suggesting possibly error in lab testing process.
040984 - ref SDS 9 E19L
040986 - ..
040987 - On 101207 0906 lab shows cholesterol LDL 96 fell 40% from 209, and HDL
040988 - 47 increased 30% from 35, after Doctor Sandhu doubled Simvastatin 40
040989 - mg per day; resulting in reduced risk of coronary artery disease (CAD)
040990 - and heart attack. ref SDS 11 E19L
040992 - ..
040993 - On 110406 1230 follow up treadmill stress test performed; initial
040994 - indications are 100% performance, with one node showing possible
040995 - slight irregularity. ref SDS 12 OF8F
040997 - ..
040998 - On 110415 0900 patient reports to Doctor Egan in Cardiology VA Clinic
040999 - Martinez hiking increased, now includes doing 11 miles twice per week.
041000 - ref SDS 13 527F
041002 - ..
041003 - On 130603 0930 Doctor Egan in Cardiology at VA Clinic Martinez
041004 - presents research in Emedicine Health showing Atorvastatin side
041005 - effects include increased thirst, increased urination, hunger, dry
041006 - mouth, fruity breath odor, drowsiness, dry skin, blurred vision.
041007 - ref SDS 15 BV4I
041009 - ..
041010 - On 131125 0005 research indicates Atorvastatin 10 Ezetimibe 10
041011 - Increase HDL 5% TG 30% Lower LDL-C 50%. ref SDS 16 PU6I
041013 - ..
041014 - On 131125 0005 research in Drugs.Com indicates Ezetimibe less common
041015 - side effects include Dizziness, Dryness or soreness of throat,
041016 - Hoarseness, which have all occurred and may compound side effects of
041017 - Atorvastatin. ref SDS 16 JO6K
041019 - ..
041020 - On 131125 0005 research yielded public reporting Tim Russert, popular
041021 - television news commentator died from heart attack despite achieving
041022 - reduction of cholesterol LDL 68, below the "gold standard" for
041023 - coronary health; yet, his HDL 37 remained very low, and he continued
041024 - overweight (metabolic syndrome). ref SDS 16 RK6O
041026 - ..
041027 - On 131125 0005 research yielded public reporting coronary CT
041028 - angiography test measures calcium present in the arteries. Tim
041029 - Russert had the scan done in 1998 with a score of 210. It should be
041030 - 0. ref SDS 16 N73K Coronary computed tomography angiography (CTA)
041031 - allows coronary artery visualization and the detection of coronary
041032 - stenoses. In addition; it has been suggested as a novel, noninvasive
041033 - modality for coronary atherosclerotic plaque detection,
041034 - characterization, and quantification. ref SDS 16 VW3W
041036 - ..
041037 - On 131125 0005 research yielded public reporting HDL > 60 are
041038 - associated with a reduced risk of coronary artery disease (CAD). HDL
041039 - "scour" the walls of blood vessels cleaning out excess cholesterol
041040 - that otherwise might have been used to make the plaques that cause
041041 - CAD. ref SDS 16 4E6H
041043 - ..
041044 - On 131125 0005 research yielded public reporting clinical trials found
041045 - that increasing HDL with drugs does not yield benefits of regressing
041046 - atherosclerotic plaques. ref SDS 16 KG9F
041048 - ..
041049 - On 131125 0005 research yielded public reporting that aerobic exercise
041050 - (any exercise, such as walking, jogging or bike riding, that raises
041051 - your heart rate for 20 to 30 minutes at a time) may be the most
041052 - effective way to increase HDL levels in a way that does appear to
041053 - lower risk of heart disease. Evidence suggests the duration of
041054 - exercise, rather than the intensity, is the more important factor in
041055 - raising HDL choleserol. ref SDS 16 SH4J
041057 - ..
041058 - On 140213 0830 meeting at VA consider performing coronary CT
041059 - angiography (CCTA) test to evaluate regression of atherosclerosis
041060 - lesions based on labs showing elevated LDL-C, but also high HDL and
041061 - low triglycerides (TG), which could signal discordance, i.e., low
041062 - LDL-P, ref SDS 19 JZ4O, which is the healthiest condition for CVD
041063 - patients, shown by research on 131125 0005. ref SDS 16 FI3G
041064 -
041065 -
041066 -
041068 - ..
0411 -
0412 -
0413 - Progress
0414 -
041401 - Doctor Simpson advised he has received no correspondence from the
041402 - patient. This indicates correspondence is incorrectly addressed, or
041403 - that the VA is intercepting the doctor's mail.
041405 - ..
041406 - The CCTA report shows the CT scan file on 151019, was created to
041407 - enable calcium scoring. 151019 0930, ref SDS 30 KS44 Since the VA
041408 - Radiology Department did not provide calcium scoring, can someone else
041409 - do this?
041411 - ..
041412 - Doctor Simpson said that after his call on 151021, advising the
041413 - radiologist report is vague on the CCTA test on 151019, ref SDS 31
041414 - FU6N, he met with the radiologist to make a joint review the CT scans
041415 - taken on 151019 0930. ref SDS 30 RF9U
041417 - ..
041418 - The scan file is located at...
041419 -
041420 - F:\05\00003\SM\CC\AGMJ\20151019-093000\GEARView.exe
041422 - ..
041423 - Doctor Simpson related during the meeting today, that he asked the
041424 - radiologist about "some gray stuff" they observed in the CT scan film,
041425 - which Doctor Simpson wondered might be small amounts of accumulating
041426 - plaque in the active artial blood vessel system. Doctor Simpson
041427 - seemed to say the radiologist indicated it could be.
041429 - ..
041430 - There was no further indication during the meeting today, that the VA
041431 - radiology department has changed or plans to change the report that
041432 - has been issued saying...
041433 -
041434 - "all bypassed grafts are patent?" ref SDS 30 JW8O
041435 -
041436 - [...below on 151028 1000 Doctor Simpson recommends patient
041437 - continue treatment with statin drugs for atherosclerosis
041438 - plaques, despite Radiology report that CCTA testing shows
041439 - all bypassed grafts are patent, meaning "clear", because
041440 - CCTA test results are imprecise, indicated by radiologist
041441 - agreeing with Doctor Simpson that some "grey stuff" shown
041442 - in the scan imaging file could be plaque. ref SDS 0 J69I
041444 - ..
041445 - [On 160104 0855 Doctor Jha, attending physician for this
041446 - CCTA imaging study, advised that standard of practice for
041447 - radiology reporting is to present any and all blockages of
041448 - any kind observable in CCTA scan imaging; so, in this case,
041449 - since none are reported, the CCTA test on 151019, can
041450 - correctely be interpretted to mean there are no blockages,
041451 - plaques, stenosis of any kind evident from the scan file
041452 - record. ref SDS 34 054G
041454 - ..
041455 - Doctor Simpson related that cholesterol and other plaque can begin
041456 - accumulating in bypass grafts within 2 years after CABG surgery.
041457 - Since CABG +4 was performed in this case 6 years ago on 091022 0700,
041458 - ref SDS 4 PQWU, the finding from testing on 151019, that all bypassed
041459 - grafts are "patent," ref SDS 30 JW8O, meaning clear of plaques, seems
041460 - to endorse line of care with extended endurance exercise and minimal
041461 - drug treatments for preventing atherosclerosis plaques from recurring,
041462 - which was prescribed by Doctor Alba during the meeting at the VA on
041463 - 140213 0830. ref SDS 19 IU4H
041465 - ..
041466 - Even this issue seems complicated. Wikipedia says in part...
041467 -
041468 - Grafts can become diseased and may partially or completely
041469 - occlude - that is, lose their patency - in the months to years
041470 - after bypass surgery is performed.
041471 -
041472 - A graft is considered patent if there is normal flow through
041473 - the graft: flow begins to diminish with around a 70 percent
041474 - stenosis in the graft.
041475 -
041476 - https://en.wikipedia.org/wiki/Coronary_artery_bypass_surgery
041478 - ..
041479 - Thus, could finding "all bypassed grafts are patent" reflect up to 70%
041480 - stenosis, according to Wikipedia's analysis?
041482 - ..
041483 - Doctor Simpson seemed to say that bypass tissue taken from near the
041484 - heart, in this case the LIMA attached to the subclavian was grafted to
041485 - the LAD, reported in Progress Notes for procedure on 091022, and
041486 - reported a year later on 100928 0706, ref SDS 10 HT9G, has better
041487 - longevity because arteries near the heart evolve to withstand higher
041488 - blood pressures than blood vessels harvested farther from the heart.
041489 - In this case, the saphenous vein was extracted by Paula from the right
041490 - leg, ref SDS 10 AI5H, and described as "good quality," in Neil's
041491 - Progress Notes for the operation 091022 (received in the record on
041492 - 100928 0706. ref SDS 10 YI7K
041494 - ..
041495 - Nominally, performance of CABG +4 in this case seems to align with
041496 - research explaining conditions for favorable to optimum outcomes -
041497 - see Wikipedia...
041498 -
041499 - https://en.wikipedia.org/wiki/Coronary_artery_bypass_surgery
041500 -
041501 - Prognosis following CABG depends on a variety of factors, and
041502 - successful grafts typically last 8?15 years.[citation needed]
041503 - In general, CABG improves the chances of survival of patients
041504 - who are at high risk (generally triple or higher bypass),
041505 - though statistically after about five years the difference in
041506 - survival rate between those who have had surgery and those
041507 - treated by drug therapy diminishes. Age at the time of CABG is
041508 - critical to the prognosis, younger patients with no
041509 - complicating diseases doing better, while older patients can
041510 - usually be expected to suffer further blockage of the coronary
041511 - arteries.
041513 - ..
041514 - Today, Doctor Simpson seemed further to say that reliability of
041515 - coronary CT angiography (CCTA) technology and work practice are
041516 - imprecise, and so test results that patient's primary coronary blood
041517 - vessles are "patent" do not justify reducing treatment with statin
041518 - drugs. He again referenced meeting with Radiology in this case, and
041519 - pointing out possible "gray stuff" as possible atherosclerosis
041520 - building up, but not cited in the Radiology report, per above.
041521 - ref SDS 0 5Y8G
041522 -
041523 - [On 160104 0855 Doctor Jha, attending physician for this
041524 - CCTA imaging study, advised that standard of practice for
041525 - radiology reporting is to present any and all blockages of
041526 - any kind observable in CCTA scan imaging; so, in this case,
041527 - since none are reported, the CCTA test on 151019, can
041528 - correctly be interpretted to mean there are no blockages,
041529 - plaques, stenosis of any kind evident from the scan file
041530 - record. ref SDS 34 054G
041532 - ..
041533 - [On 160114 0022 letter commends Doctor Jha and faculty
041534 - colleagues at UCSF for good faith review to clarify CCTA on
041535 - 151019, that demonstrates CCTA evaluating response to
041536 - treatment (hiking 10K miles raising HDL 30 to 70) for
041537 - regressing atherosclerosis to 0. ref SDS 36 N760
041539 - ..
041540 - Doctor Simpson explained during the meeting today, cardiology policy
041541 - avoids CCTA testing patients for resonse to treatment that regresses
041542 - atherosclerotic plaque, as done in oncology using radiology tools (CT,
041543 - PET scans) to assess response to treatments for regressing cancer that
041544 - enables reducing debilitating treatment side effects. Instead,
041545 - cardiology treats patients with statin in hopes of slowing progression
041546 - of calcium plaques based solely on secondary lab metrics, without
041547 - looking to see what is actually occurring in the body. This explains
041548 - resistance the past 2 years against ordering radiology CCTA for
041549 - testing response to treatment in this case.
041551 - ..
041552 - The doctor noted there are no clinical trials showing statin drugs
041553 - regress atherosclerosis plaques to lower patient risks for CVD,
041554 - myocardial infarction and stroke. Clinical studies have shown statins
041555 - increase longevity for many patients. Doctor Simpson noted a larger
041556 - base of clinical studies is needed showing the efficacy of CCTA for
041557 - guiding treatments in cardiology.
041559 - ..
041560 - There was further discussion that patients seek longevity with quality
041561 - of life worth living. Side effects of drugs like statins severely
041562 - debilitate some patients, like chemotherapy impairs quality of life
041563 - for cancer patients.
041565 - ..
041566 - Over the past 6 years, the medical team through doctor/patient
041567 - partnership have experimented with clinical protocols prescribing
041568 - minimal drugs that avoid harsh side effects, and combined with
041569 - extended endurance exercise to regress atherosclerosis, rather than
041570 - merely slow progression of coronary artery disease (CAD). These
041571 - clinical trials have yielded favorable results in lipid labs. It
041572 - therefore seems reasonable to perform radiology CCTA to evaluate if
041573 - favorable lipid labs raising HDL 30 to HDL 70 the past few years, has
041574 - regressed atherosclorosis that would in turn support reducing
041575 - debilitating statin treatments.
041577 - ..
041578 - The doctor asked about current protocol?
041580 - ..
041581 - On 131230, began taking Atorvastatin 10 mg and Ezetimibe 10 mg, shown
041582 - in case study on 120101 0900, ref SDS 14 6A6H, and prescribed by
041583 - Doctor Alba and Doctor Feingold during a meeting on 131219 0930.
041584 - ref SDS 17 6H6K
041586 - ..
041587 - Doctor Simpson advised that Atorvastatin 10 mg is a very small dose.
041589 - ..
041590 - We reviewed prior discussion of severe side effects on 151014,
041591 - ref SDS 29 2Q3I, considering Doctor Wisneski's comments on 151005,
041592 - that adverse side effects of statins can be minimized by lowering the
041593 - dose or taking statin drugs every other day. ref SDS 28 GL7G
041595 - ..
041596 - Doctor Simpson explained popular cardiology practice to prescribe
041597 - maximum dose of statin drug treatments that can be tolerated. He
041598 - proposed resuming statin treatment in this case with Atorvastatin 80
041599 - mg, and not resuming Ezetimibe.
041601 - ..
041602 - Evidence in this case indicates Atorvastatin 10 mg and Ezetimibe 10 mg
041603 - is the maximum regimen that can be tolerated, reported in the record
041604 - on 140809, shown in case study on 140101 0600. ref SDS 18 GH3G
041606 - ..
041607 - Presented plans to resume today taking Atorvastatin 10 mg with
041608 - Ezetimibe 10 mg, since this protocol has been effective lowering
041609 - cholosterol LDL-P count the past 2 years, and in combination with
041610 - extended endurance exercise hiking 11 miles per day (recently
041611 - increased to 15 miles per day), 300 miles per month, and 10,000 miles
041612 - the past 4 years, has yielded HDL 70 and LDL P 656, while increasing
041613 - LDL particle size to "type A". Research indicates these 2 conditions
041614 - (LDL-P < 1000 and particle size type A) resist progression of
041615 - atherosclerosis. Additionally, patient exercise protocol increased
041616 - HDL 30 prior to CABG +4 surgery on 091022, and after hiking 10,000
041617 - miles increased to HDL 70, reported in the lab on 150209 1012.
041618 - ref SDS 20 U45J Research indicates HDL 70 "rapidly regresses"
041619 - atherosclerosis and the CCTA test on 151019, made findings that
041620 - bypass grafts are patent 6 years after CABG +4 surgery.
041622 - ..
041623 - We reviewed evidence in this case showing minimal dose of drugs
041624 - minimizes side effects, so that extended endurance exercise hiking 11
041625 - miles per day and recently 15 miles per day, can continue to yield
041626 - favorable lipids that prevent and regress atherosclerotic plaques to
041627 - lower risks of CVD, as shown in the CCTA on 151019.
041629 - ..
041630 - Doctor Simpson asked how much time these hikes take?
041632 - ..
041633 - Daily diet, exercise, medication, and vitals are shown in patient
041634 - history on 140101 0600. ref SDS 18 TTPX This shows the time varies
041635 - according to daily energy levels, and injury status - for 11 miles
041636 - from best of 158 minutes to about 215 minutes. The past year daily 11
041637 - miles take about 165 minutes, but since the fall hiking Half Dome on
041638 - 150916, times have increased to 185 minutes. Within the past 2
041639 - months have added another 4 mile loop to make total distance 15
041640 - miles, and this takes another 60 minutes.
041642 - ..
041643 - Mileage and times are summarized in a spreadsheet...
041644 -
041645 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
041647 - ..
041648 - Doctor Simpson commented these are "fast" hiking times for 11 and 15
041649 - miles.
041651 - ..
041652 - The doctor asked about losing weight? He cited the VA's reliance on
041653 - standardized BMI criteria.
041655 - ..
041656 - Stood up and raised my shirt, so the doctor could examine for excess
041657 - fat. He seemed to feel the patient does not appear overweight, which
041658 - aligns with hiking 300 miles per month.
041660 - ..
041661 - Patient weighs about 175 pounds today, down from 205 several years
041662 - ago, and continues to work toward 165. Accordingly, like generalized
041663 - conclusions about taking statins, reliance on generalized BMI
041664 - standards may be misplaced, since genetic variability obviates
041665 - application in this case.
041667 - ..
041668 - Doctor Simpson asked about diet, specifically about how much the
041669 - patient eats for breakfast before hiking?
041671 - ..
041672 - Daily diet, exercise, medication, and vitals listing patient history
041673 - on 140101 0600, ref SDS 18 TTPX, shows hiking sometimes occurs at
041674 - 0300, 0400, 0500, actually throughout the day until as last as 1700 in
041675 - the evening, though late afternoon hikes are rare. Patient history
041676 - further shows the patient never eats before hiking.
041678 - ..
041679 - In recent weeks doing 15 mile hikes, on 2 occasions have had cherrios
041680 - and strawberries with milk before these longer hikes. This has seemed
041681 - helpful, though it was omitted for the hike yesterday, since lipid
041682 - labs require fasting, shown on, ref SDS 18 1S7H
041684 - ..
041685 - Doctor Simpson used the computer in the office to order refills for
041686 - Atorvastatin and Ezetimibe.
041688 - ..
041689 - Scheduled follow up in 3 months to review progress toward normalizing
041690 - lipids (cholesterol 160, LDL-P < 1000, TG 50, HDL 70).
041691 -
041692 -
041693 -
041695 - ..
0417 -
0418 -
0419 - 1043
0420 -
042001 - After the meeting, visited the clerk at Module 1.
042002 -
042003 - Scheduled next meeting with Doctor Simpson on 160203 1000.
042004 -
042005 -
042006 -
0421 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Medical Chart Progress Notes for Cardiology Meeting 151028
050403 - Progress Notes Cardiology Meeting 151028 Doctor Simpson
050404 - Doctor Simpson Progress Notes Cardiology Meeting 151028
050405 -
050406 - Follow up ref SDS 29 PF5K, ref SDS 21 6Y7H.
050407 -
050408 - VA Progress Notes for meeting with health care providers are
050409 - available at...
050410 -
050411 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
050412 -
050424 -
050425 - 1. Date/Time: 28 Oct 2015 @ 1134
050426 - Note Title: CARDIOLOGY CLINIC ATTENDING NOTE (MED)
050427 - Location: San Francisco CA VAMC
050428 - Signed By: SIMPSON,PAUL C
050429 - Co-signed By: SIMPSON,PAUL C
050430 - Date/Time Signed: 28 Oct 2015 @ 1221
050431 - -------------------------------------------------------------------------
050433 - ..
050434 - 2. LOCAL TITLE: CARDIOLOGY CLINIC ATTENDING NOTE (MED)
050435 - STANDARD TITLE: CARDIOLOGY ATTENDING NOTE
050436 - DATE OF NOTE: OCT 28, 2015@11:34 ENTRY DATE: OCT 28, 2015@11:34:16
050437 - AUTHOR: SIMPSON,PAUL C EXP COSIGNER:
050438 - URGENCY: STATUS: COMPLETED
050444 - ..
050445 - 3. Most Recent VITAL SIGNS:
050446 - Height: 64.5 in [163.8 cm] (09/23/2015 15:32)
050447 - Weight: 180.5 lb [82.0 kg] (10/28/2015 08:56)
050448 - BMI: 30.5 (Obesity Level I)
050449 - Temp: 97.8 F [36.6 C] (10/05/2015 08:40)
050450 - Pulse: 78 (10/28/2015 08:56)
050451 - Comments:
050453 - ..
050454 - Resp: 16 (10/05/2015 08:40)
050455 - BP: 123/63 (10/28/2015 08:56)
050457 - ..
050458 - O2 Sat: 10/28/15 08:56:38 O100
050459 -
050460 - 4. 70 swm returns to f/u cor CTA and use or not of statins.
050462 - ..
050463 - 5. CARD PROBLEMS:
050464 -
050465 - 1) CAD sp CABG here 10-22-09 (LIMA, SVG diag, ramus, PDA)
050466 - last TTE here 10-26-09 wnl
050467 - last seen CT Surg 11-19-09, never cards
050468 - cor CTA 10-19-15 all grafts open (by my discn w radiol, some lumps
050469 - proximal left SVGs, ca score >1000)
050470 -
050471 - 2) hyperlipidemia LDL 170 12-14-09; lately ok, then bad again off statin, see
050472 - below
050473 -
050474 - 3) overwt/obesity (BMI ~30)
050476 - ..
050477 - 6. OTHER:
050478 -
050479 - 1) achalasia sp ops
050480 - 2) recent LLE hematoma w cellulitis sp fall (adm here 9-23 to 9-25-15)
050481 - 3) recent fx R radius (same fall)
050483 - ..
050484 - 7. ASSESS:
050485 -
050486 - -He continues to do very well clinically, can walk 15 miles.
050487 -
050488 - -Lipids deteriorated off statin.
050489 -
050490 - -CRP-HS is high also (5).
050492 - ..
050493 - -Cor CTA shows open grafts, but is not sufficient resolution to
050494 - serve as an endpoint for worse or better athero; in fact, the
050495 - study could be read as showing some easrly changes in the SVGs.
050496 - This is about what I had predicted.
050498 - ..
050499 - During the meeting on 151014, prior to CCTA on 151019, Doctor Simpson
050500 - asked about work plan if CCTA results show evidence of
050501 - atherosclerosis? ref SDS 29 4F5I
050503 - ..
050504 - Doctor Simpson's comment presenting possible interpretation of CCTA
050505 - showing "early changes in SVGs [saphenous vein grafts], reflects issue
050506 - of longevity of 3 SVGs performed on 091022. 091022 0700, ref SDS 4
050507 - 156H
050508 -
050509 - [On 160203 1000 Progress Notes do not present correlations
050510 - of addendum filed OA 160113, 160113 2234, ref SDS 35 A85F,
050511 - with concern about possible "... early changes in the
050512 - SVGs," filed with Progress Notes on 151028. ref SDS 37 W16I
050514 - ..
050515 - Progress Notes continue...
050516 -
050517 - -He remains worried re statin SEs, mainly xs urination and
050518 - dry/cracked feet.
050520 - ..
050521 - 8. PLAN:
050522 -
050523 - -We had another long discussion of the pros and cons. He is
050524 - very well versed on the science, and he keeps careful track of
050525 - his records and data.
050527 - ..
050528 - -I explained that athero and occlusion of SVGs is a special
050529 - ongoing concern, and statins are rec'd post-CABG by clinc
050530 - trials.
050532 - ..
050533 - -We went over diet and lifestyle, which for him are atypical
050534 - (one meal a day, not much sleep, early AM walks) but healthy.
050535 - He does want to lose some wt to about 160 (about 175 now).
050537 - ..
050538 - -He plans to resume lipid rx at prior levels 10 atrrva and 10
050539 - ezet. I refilled as needed.
050540 -
050541 - -My strong suggestion is high intensity statin.
050542 -
050543 - -I will see again in 3 mos. Labs ordered for then.
050544 - -still need to review if/why no aspirin?
050546 - ..
050547 - 9. HPI:
050549 - ..
050550 - He continues to do quitre well. Often walking 15 miles a day
050551 - w/o sxs. Gets up 3-6 am often to walk, bed early am, so not
050552 - much sleep. one meal a day in evening, but healthy (fish,
050553 - avocados, vegs).
050554 -
050555 - he thinks berts bees helped his feet.
050557 - ..
050558 - 10. Active Medications:
050559 -
050560 - 1) ATORVASTATIN CALCIUM 20MG TAB TAKE ONE-HALF TABLET restart now
050561 - ORALLY AT BEDTIME FOR CHOLESTEROL
050562 - 2) CLOTRIMAZOLE 1% TOP CREAM APPLY CREAM TOPICALLY TWICE
050563 - A DAY UNDER AFFECTED TOE
050564 - 3) EZETIMIBE 10MG TAB TAKE ONE TABLET ORALLY EVERY DAY restart now
050565 - 4) FAMOTIDINE 20MG TAB TAKE ONE TABLET ORALLY AT BEDTIME
050566 - FOR STOMACH
050567 - 5) GAUZE PAD 4IN X 4IN 12-PLY STERILE USE GAUZE AS
050568 - DIRECTED TO COVER WOUND PACKING.
050569 - 6) HYDROCODONE 5MG/ACETAMINOPHEN 325MG TAB TAKE 1 TO 2
050570 - TABLETS ORALLY EVERY 6 HOURS AS NEEDED FOR PAIN
050571 - 7) KERLIX 4.5IN STERILE USE BANDAGE AS DIRECTED TO WRAP
050572 - LOOSELY AROUND WOUND.
050573 - 8) TAPE,MICROPORE 2IN 3M #1530-2 USE TAPE AS DIRECTED
050574 -
050576 - ..
050577 - 11. Computerized Problem List is the source for the following:
050578 -
050579 - 1. History of coronary artery bypass grafting, 10/14/2015
050580 - Onset 10/00/2009
050581 - SFVA LIMA, SVGs diag, ramus, PDA
050582 - 4) Hyperlipidemia 10/14/2015
050583 - 5) Body mass index 30+ - obesity 10/14/2015
050584 - 6) Chronic ischemic heart disease 10/14/2015
050585 - 7) Esophageal Achalasia * (ICD-9-CM 530.0) 12/08/2009
050587 - ..
050588 - VS above ok
050589 - BMI is high, but he does not appear fat, x some abdominal fat.
050590 -
050592 - ..
050593 - 12. Labs
050595 - ..
050596 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050597 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050599 - ..
050600 - Report Released Date/Time: Oct 27, 2015@13:53
050601 - Provider: SIMPSON,PAUL C
050602 - Specimen: SERUM. CH 1027 664
050603 - Specimen Collection Date: Oct 27, 2015@11:52
050604 - Test name Result units Ref. range Site Code
050605 - HEMOGLOBIN A1C 5.5 % 4.0 - 6.0 [662]
050606 - ===============================================================================
050607 -
050608 -
050610 - ..
050611 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050612 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050614 - ..
050615 - Report Released Date/Time: Oct 27, 2015@12:50
050616 - Provider: SIMPSON,PAUL C
050617 - Specimen: PLASMA. CH 1027 662
050618 - Specimen Collection Date: Oct 27, 2015@11:52
050619 - Test name Result units Ref. range Site Code
050620 - CRP-HS 5.1 mg/L 0.2 - 7.5 [662]
050621 - Eval: Inflammation reference range: 0.2 - 7.5 mg/L
050622 - Eval: For assessment of risk for cardiovascular disease in adults,
050623 - Eval: the CDC and AHA recommend the following guidelines based on two
050624 - Eval: test results, two weeks apart in metabolically stable patients:
050625 - Eval:
050626 - Eval: Cardiovascular Disease Risk CRP-HS mg/L
050627 - Eval: Low......................<1.0
050628 - Eval: Average......................1.0-3.0
050629 - Eval: High.......................>3.0 - 10.0
050630 - Eval: Indeterminate...................>10
050631 - Eval:
050632 - Eval: If CRP-HS level is >10 mg/L, the patient should be evaluated
050633 - Eval: for possible sources of infection or inflammation. Repeat CRP-HS
050634 - Eval: may also be appropriate.
050635 -
050637 - ..
050638 - CHOLESTEROL 315 H mg/dl 100 - 240 [662]
050639 - TRIGLYCERIDE 59 mg/dl 10 - 190 [662]
050640 - HIGH DENSITY LIPOPROT (HDL) 60 mg/dl Ref: >=35 [662]
050641 - Eval: HDL <35 is associated with increased risk of CAD.
050642 - LDL CHOL(Calculated) 243 H mg/dl Ref: <=131 [662]
050643 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050644 - ===============================================================================
050645 -
050647 - ..
050648 - Clinical Reminder Activity
050649 - MED REC NON PRIMARY CARE:
050650 - Current medications reviewed with patient/caregiver and reconciliation
050651 - of medications related to today's visit completed, including non-VA
050652 - medications and discrepancies, if identified, were addressed.
050653 - Medication changes and the importance of medication management were
050654 - reviewed with the patient/caregiver today based on individual needs.
050655 - Patient/caregiver acknowledged understanding of instructions as
050656 - stated. An updated list of reconciled medications has been provided
050657 - to the patient/caregiver.
050658 -
050659 - 13. /es/ Paul C. Simpson MD
050660 - Attending MD Cardiology, NPI 1548374093
050661 - Signed: 10/28/2015 12:21
050663 - ..
050664 - Receipt Acknowledged By:
050665 - 11/09/2015 14:29 /es/ MADHU RAO
050666 - Staff Physician
050667 - 10/28/2015 14:28 /es/ JUDITH A WISNESKI, MD
050668 - Medicie/Cardiology attending (VA2010)
050669 -
050670 -
050671 -
050672 -
050673 -
050674 -
050675 -
050676 -
050677 -
050678 -
050679 -
050680 -