THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com
S U M M A R Y
DIARY: December 15, 2015 01:30 PM Tuesday;
Rod Welch
VA meeting with Doctor Stewart Module 2 Surgery Clinic on debridement surgery left leg.
1...Summary/Objective
2...Medical Chart Progress Notes for General Surgery Meeting 151215
3...Progress Notes General Surgery Meeting 151215 Doctor Stewart and Lana
4...Doctor Stewart and Lana Progress Notes General Surgery Meeting 151215
ACTION ITEMS..................
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1...He may be able to prescribe a statin with less severe side effects,
CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 10 0000. ref SDS 7 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Meeting in Clinic Module 2 planned by Doctor Stewart during the
040902 - meeting on 151110 0130. ref SDS 10 IP42 Follows up, care by Lana last
040903 - Friday on 151211 0830. ref SDS 15 LX7H
040905 - ..
040906 - Visit Radiology get CD with files for xray and CT scan right wrist
040907 - performed on 151005. It was ordered on 151104 1315. ref SDS 9 PR4G
040909 - ..
040910 - Doctor Stewart did this meeting herself, without assistance of
040911 - resident. Could be that staff was allowed time off for Christmas.
040913 - ..
040914 - The doctor was caughing and sneezing, and did not look well. Doctor
040915 - Stewart said she cannot take time-off to recover, because there is
040916 - nobody else to care for her patients. She will take a week off-work
040917 - next week for the holidays, and hopes to rest and recover.
040919 - ..
040920 - Doctor Stewart asked how the wound is recovering?
040922 - ..
040923 - Reported improved progress, since switching to Hydrofera Blue
040924 - Bacterostatic dressing on 151130 0800. ref SDS 11 3Q8M
040925 -
040926 - [On 160418 0810 letter to Lana requesting re-supply of
040927 - Hydrofera Blue dressing for new debridement wound on big
040928 - toe left foot. ref SDS 17 NX45
040930 - ..
040931 - While we talked, a nurse came into the room. Doctor Stewart asked the
040932 - nurse if she can change the Hydrofera Blue wound dressing. The nurse
040933 - said she has never done it. The doctor asked the nurse to go find
040934 - Lana and advise she is needed to change the dressing.
040936 - ..
040937 - The nurse said that Lana is with another patient.
040939 - ..
040940 - Doctor Stewart said she can take 5 minutes to change this dressing.
040942 - ..
040943 - The nurse left the room to get Lana.
040945 - ..
040946 - While waiting for Lana, discussed issue of statin side effects causing
040947 - liver dysfunction shown by frequent urination, dehydration. Recently,
040948 - on 151215, Doctor Hewitson in Podiatry Biomechanics diagnosed rising
040949 - injuries to feet from dehydration. 151215 1000, ref SDS 16 MG6U
040950 - Bilirubin has been elevated the past 2 years while takig Atorvastatin
040951 - 10 mg.
040953 - ..
040954 - Doctor Stewart recommended discussing the matter with Doctor Simpson.
040956 - ..
040957 - He may be able to prescribe a statin with less severe side effects,
040958 - even though it does not lower LDL cholesterol to meet nominal
040959 - Cardiology goals. Since benefits of HDL 70, which enabled regression
040960 - of atherosclerotic plaques, shown by CCTA on 151019, ref SDS 8 JW8O,
040961 - and explained by Doctor Elicker on 151203, ref SDS 13 SZ5F, is
040962 - achieved through extended endurance exercise, here hiking 10,000 miles
040963 - the past 4 years, then elevated LDL lipid profile may be acceptable,
040964 - with follow up CCTA testing every 6 or 12 months that verifies
040965 - continuing evidence of no atherosclerotic plaques.
040967 - ..
040968 - About 3 minutes later, Lana came into the room. She brought with her
040969 - materials needed to change the dressing.
040971 - ..
040972 - Lana used scissors to cut existing bandaging from the lower left leg,
040973 - which she had placed last Friday on 151211 0830. ref SDS 15 LX7H
040974 - Since Lana was rushed to get back to her other patient, we did not
040975 - take pictures today showing progress of wound recovery.
040977 - ..
040978 - Doctor Stewart examined the open wound and commented healing is
040979 - occurring very well. She commended Lana for good work healing a
040980 - difficult wound, which was considered for surgical reconstruction
040981 - during the meeting on 151006 1315. ref SDS 7 LJ8N Today, the doctor
040982 - feels this will not be required, because the wound will fully recover
040983 - to match surrounding skin.
040985 - ..
040986 - Lana read wound dimensions for Doctor Stewart to report in Progress
040987 - Notes which she was typing with the computer in the examination room.
041000 - ..
041001 - Lana then cut a section of Hydrofera Blue Bacterostatic dressing to
041002 - fit the wound. She used a syringe to moisten with sterile liquid and
041003 - placed the moistened dressing to cover the hematoma wound on the lower
041004 - left leg. Doctor Stewart asked how to spell "Hydrofera Blue", so
041005 - helped her with spelling. Patient wrapped the dressing with 4" gauze
041006 - and then Kobin 4" elastic bandaging, which is protocol followed since
041007 - 150928. Lana then applied elastic netting to protect the bandaing
041008 - system.
041010 - ..
041011 - [On 160418 0810 letter to Lana requesting re-supply of
041012 - Hydrofera Blue dressing for new debridement wound on big
041013 - toe left foot. ref SDS 17 NX45
041015 - ..
041016 - After completing wound dressing, Lana scheduled next follow up in
041017 - Wound Care Clinic on Friday, 151218 0800.
041019 - ..
041020 - Lana again prescribed customer remove wrapping, apply moistening wound
041021 - dressing protocol, and wrap the Hydrofera Blue Bacterostatic wound
041022 - dressing again, on Thursday, 151217, as explained on 151207 0800.
041023 - ref SDS 14 1E3F This will be performed as done this past Sunday on
041024 - 151213, shown in case study on 140101 0600. ref SDS 1 MU6G
041026 - ..
041027 - Doctor Stewart thanked Lana for excellent work. Lana then rushed back
041028 - to her other patient. This work today demonstrated teamwork,
041029 - coordination, and collaboration among doctors implementing
041030 - doctor/patient partnership that optimizes outcomes.
041032 - ..
041033 - Doctor Stewart wants another follow up with surgery. She used the
041034 - computer in the examination room to enter in the VA schedule a
041035 - meeting on 160119.
041037 - ..
041038 - Thanked Doctor Stewart and commended Lana's work the past 3 months in
041039 - Wound Care Clinic.
041041 - ..
041042 - Wished Doctor Stewart Merry Christmas, and speedy recovery from her
041043 - cold/flue.
041045 - ..
041046 - On leaving the clinic saw Lana in the doorway of another examination
041047 - room. She was smiling. Apologized for interrupting her care for
041048 - another patient, per above. ref SDS 0 D95M She said everything worked
041049 - out okay.
041051 - ..
041052 - Stopped at the front desk. Megan scheduled next meeting with Lana in
041053 - Wound Care for 151218 0800.
041055 - ..
041056 - Megan also confirmed schedule for another meeting with Doctor Stewart
041057 - on 160119 1315, per the doctor's work plan, above. ref SDS 0 QO9I
041058 -
041059 -
041060 -
041061 -
041062 -
041063 -
0411 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Medical Chart Progress Notes for General Surgery Meeting 151215
050403 - Progress Notes General Surgery Meeting 151215 Doctor Stewart and Lana
050404 - Doctor Stewart and Lana Progress Notes General Surgery Meeting 151215
050405 -
050406 - Follow up ref SDS 7 DK5K.
050407 -
050408 - Progress Notes are one entry of several files stored on CD received
050409 - from VA on 151218, and includes General Surgery meeting on 151215
050410 - 0130; Doctor Stewart entered her Progress Notes at 1353...
050411 -
050412 - F:\05\00003\SM\CC\AGMJ\20151215-135346\w0144_welch_12 15 15.pdf
050414 - ..
050415 - LOCAL TITLE: SURGERY (GENERAL) CLINIC
050416 - STANDARD TITLE: SURGERY OUTPATIENT NOTE
050417 - DATE OF NOTE: DEC 15, 2015@13:53 ENTRY DATE: DEC 15, 2015@13:53:46
050418 - AUTHOR: STEWART,LYGIA EXP COSIGNER:
050419 - URGENCY: STATUS: COMPLETED
050421 - ..
050422 - Vital Signs:
050423 - Height: 64.5 in [163.8 cm] (09/23/2015 15:32)
050424 - Weight: 187.9 lb [85.4 kg] (12/11/2015 08:18)
050425 - BMI: 31.8 (Obesity Level I)
050426 - BP: 136/77 (12/11/2015 08:18)
050427 - Resp: 16 (10/05/2015 08:40)
050428 - Pulse: 77 (12/11/2015 08:18)
050429 - O2 Sat: 12/11/15 08:18:01 O98
050430 - Pain: 0 (12/11/2015 08:18)
050432 - ..
050434 - ...is a 70 year old man who is receiving treatment following I &
050435 - D of an infected hematoma, with LLE cellulitis (on 9/23/15).
050436 - The area is being treated with Hydrofera Blue with BId wound
050437 - changes.
050439 - ..
050440 - Exam: WDWN man in NAD. The wound looks very good, with healthy
050441 - granulation tissue, it is 2.2 X 0.8 cm in size.
050443 - ..
050444 - Impression: the wound is healing very well with current Tx. We will
050445 - continue.
050447 - ..
050448 - RTC 1/19/15
050450 - ..
050451 - Clinical Reminder Activity
050453 - ..
050454 - MED REC NON PRIMARY CARE:
050456 - ..
050457 - Current medications reviewed with patient/caregiver and reconciliation
050458 - of medications related to today's visit completed, including non-VA
050459 - medications and discrepancies, if identified, were addressed.
050460 - Medication changes and the importance of medication management were
050461 - reviewed with the patient/caregiver today based on individual needs.
050462 - Patient/caregiver acknowledged understanding of instructions as
050463 - stated. An updated list of reconciled medications has been provided
050464 - to the patient/caregiver.
050465 -
050466 - /es/ Lygia Stewart, M.D., 2860
050467 - Chief General Surgery, Assoc Chief Surgery
050468 - Signed: 12/15/2015 14:02
050469 -
050470 -
050471 -
050472 -
050473 -
050474 -
050475 -
0505 -