CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 47 0000. ref SDS 43 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040507 -
040508 -
040510 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Met initially with Doctor Andrew Larsen, 1st year Intern.
040903 - ..
040904 - He asked about the purpose of the meeting.
040906 - ..
040907 - Cited the letter to Doctor Stewart submitting the agenda and issued on
040908 - 160118 0124. ref SDS 47 NV5I
040910 - ..
040911 - Andrew then recalled seeing the letter. He pulled from a pocket in
040912 - his lab coat, the copy of the letter submitted earlier today during
040913 - check in.
040915 - ..
040916 - Doctor Larsen asked about history of hematoma on left leg.
040918 - ..
040919 - Explained...
040920 -
040921 - 1. Hematoma injury on lower left leg occurred hiking Half Dome in
040922 - Yosemite on 150916, ref SDS 20 O87H, and was reported to
040923 - medical team in the letter to VA Primary Care on 150917 1028.
040924 - ref SDS 21 JN3J Doctor Rao made timely referral to ER, with
040925 - guidance on background of injury. ref SDS 21 NC9M
040927 - ..
040928 - 2. Examination determined no treatment was needed on 150917, in ER
040929 - at VA Medical Center San Francisco, ref SDS 21 PSRR, as shown in
040930 - the letter to Primary Care on 150920 1917. ref SDS 22 MS63
040932 - ..
040933 - 3. Rising pain to level "20" on standing up, from left leg injury
040934 - was reported to Primary Care in a letter on 150920 1917.
040935 - ref SDS 22 MS73 Primary Care scheduled follow up meeting 3 days
040936 - later on 150923.
040938 - ..
040939 - 4. On 150923, Primary Care examined wound and made referral to
040940 - Surgery Department for assessment. ref SDS 23 499K About 3
040941 - hours later, Surgery department medical team performed follow
040942 - up examination in Medical Practice (Primary Care) Clinic and
040943 - diagnosed possible infection causing elevated pain level "20";
040944 - referred patient to ER and coordinated ordering lab to verify
040945 - infection. ref SDS 23 ET4T In the ER infection with cellulitis
040946 - was diagnosed with WBC 13.6 on 150923 1530. ref SDS 23 ZF4J
040948 - ..
040949 - 5. Minor surgical debridement procedure performed by Doctor
040950 - Jessica Della Valle in ER without conscious sedation on 150923
040951 - 1530. ref SDS 23 2O4M
040953 - ..
040954 - 6. Admitted to hospital for evaluation recovery infection; wound
040955 - treated with Hydrofera Blue Bacteriostatic dressing on 150925
040956 - 0336. ref SDS 24 DP4K Patient discharged from hospital later on
040957 - 150925 0336 at 1553. ref SDS 24 GQ8F
040959 - ..
040960 - 7. Treated by Lana twice a week in Surgery Wound Care beginning on
040961 - 150928 0900. ref SDS 25 NV5I
040963 - ..
040964 - 8. Additional debridement performed by Lana in Wound Care on
040965 - 151001 1200. ref SDS 26 NC9G
040967 - ..
040968 - 9. Additional debridement performed in Surgery Clinic follow up
040969 - examination on 151006 1315. ref SDS 29 PU7T and with
040970 - consideration for reconstructive (plastic) surgery. ref SDS 29
040971 - LJ8N
040973 - ..
040974 - 10. Doctor Stewart oversight examination and commended Lana's
040975 - excellent outcome in this case, reported on 151215 1330.
040976 - ref SDS 43 5X5L Doctor Stewart scheduled the meeting today, to
040977 - verify results. ref SDS 43 QO9I
040979 - ..
040980 - 11. Continued twice weekly care in Wound Clinic. Lana determined
040981 - the wound was fully closed in a meeting on 160104 0800.
040982 - ref SDS 44 LX7H
040984 - ..
040985 - While listening to case background, Doctor Larsen examined the wound.
040986 - He asked about pain and complications.
040988 - ..
040989 - Advised there has been no pain, and no evident complications since
040990 - meeting with Lana in Wound Care on 160104 0800. ref SDS 44 LX7H
040992 - ..
040993 - After hearing case background and completing initial examination,
040994 - Doctor Larsen left to brief Doctor Stewart.
040995 -
040997 - ..
0410 -
0411 -
0412 - 1416
0413 -
041301 - Doctor Stewart and Doctor Larsen returned to examination room.
041302 -
041303 - Doctor Stewart said she received the letter submitted on 160118 0124.
041304 - ref SDS 47 NV5I
041306 - ..
041307 - The doctor seemed well, working at her normal high energy level, fully
041308 - recovered from cold/flu symptoms, and is now well rested after a week
041309 - or so vacation over the holidays, referencing meeting on 151215 1330.
041310 - ref SDS 43 NJ8L She explained having missed only 1 day of work to
041311 - recover.
041313 - ..
041314 - Did not have time today, to discuss articles submitted with the letter
041315 - on 151119, ref SDS 33 4X5I, where research on CCTA from one of the
041316 - articles, ref SDS 33 7N6J, was presented to Radiology on 160108 2106,
041317 - ref SDS 45 TE51, and yielded addendum to original CCTA on 151019, as
041318 - reported on 160113 2234. ref SDS 46 A85F. This may guide care toward
041319 - reducing reliance on statins, consequently reducing side effects, as
041320 - set out in the letter on 160114, to the medical team with copy to the
041321 - doctor.
041323 - ..
041324 - Did not have time today, to discuss Ubiquinol for CoQ10 replacement,
041325 - presented in letter on 151124. ref SDS 34 4X5I Preliminarily this has
041326 - been very effective, reported to Doctor Stewart in the letter on
041327 - 160118 0124. ref SDS 47 X695
041329 - ..
041330 - Lana was off work today, and so could not join the meeting today, as
041331 - she did during our last meeting on 151215, and was presented in the
041332 - letter on 160118 0124. ref SDS 47 X658
041334 - ..
041335 - Doctor Stewart examined hematoma wound on lower left leg. She was
041336 - aware of minor bleeding and wound seems rougher, reported in the
041337 - letter on, ref SDS 47 X66Q, since last meeting 2 weeks ago in Wound
041338 - Care on 160104. ref SDS 44 LX7H The doctor was very pleased with
041339 - progress of recovery and feels no further medical care is required.
041340 - This aligns with Lana's assessment on 160104 0800. ref SDS 44 IZ5J
041342 - ..
041343 - Doctor Stewart examined left leg and observed atrophy of calf muscle,
041344 - cited in the letter to the medical team on 160118 0124. ref SDS 47
041345 - X66T She advised this will recover normal size and strength with
041346 - patient continued regimine of hiking 300 miles per month.
041348 - ..
041349 - Acalasia swallowing issue was discussed presented in the letter on
041350 - 160118 0124. ref SDS 47 X655
041352 - ..
041353 - Doctor Stewart was disappointed LESV contracted to lowest level in
041354 - patient history (10 mm) found during most recent EGD dilation
041355 - procedure on 151204. ref SDS 38 LC98
041357 - ..
041358 - L E S V D I A L A T I O N
041359 - Months from - to
041360 - Interval Date mm mm
041361 - 8 151204 10 15.....triamcinolone.... ref SDS 38 HU42
041362 - 6 150421 16.5 18.....triamcinolone.... ref SDS 18 HU42
041363 - 6 141107 15 18.....triamcinolone.... ref SDS 16 I167
041364 - 6 140509 16.5 18...................... ref SDS 15 P680
041365 - 7 131115 16.5 18.....triamcinolone.... ref SDS 13 RZ45
041366 - 3 130416 18 18.....triamcinolone.... ref SDS 12 Y850
041367 - 4 130110 15 18.....triamcinolone.... ref SDS 11 Q333
041368 - 6 120925 15 18.....triamcinolone.... ref SDS 10 XB51
041369 - 4 120322 16.5 18...................... ref SDS 9 516N
041370 - 3 111115 16.5 18...................... ref SDS 8 IR57
041371 - 4 110819 15 16.5...triamcinolone.... ref SDS 7 J978
041372 - 3 110429 13 16.5...triamcinolone.... ref SDS 6 U23I
041373 - 3 110218 11 14.....triamcinolone.... ref SDS 5 AA5O
041374 - 4 101210 11 14...................... ref SDS 4 H347
041375 - 5 100827 11 15...................... ref SDS 3 JE6X
041376 - 3 100305 11 15...................... ref SDS 2 WR6L
041377 - 091216 Heller Myotomy Fundoplication ref SDS 1 KE9U
041379 - ..
041380 - Explained contraction to 10 mm last month on 151204, from 18 mm
041381 - dilated on 150421, may have been due in part to scheduling delays
041382 - that extended planned dilation on 6 month interval that got extended
041383 - to 8 months due in part to patient scheduling issues.
041385 - ..
041386 - Doctor Stewart was pleased Doctor Lee in GI Clinic, VA Medical Center
041387 - in Sacramento has a strong work plan returning EGD dilation intervals
041388 - from 6 months back to 3 - 4 months, reported on 151210 0800.
041389 - ref SDS 40 UR5K. She seemed to say patient history indicates 3 month
041390 - intervals were effective until LESV is restored to 18 mm, as done
041391 - previously, per above. ref SDS 0 XG6I
041393 - ..
041394 - Doctor Stewart raised prospects of surgical repairing fundoplication
041395 - to restore protection of LESV from ulceration and hiatal hernia, first
041396 - reported in the record on 150319 0800. ref SDS 17 N46G We reviewed
041397 - briefly prior discussions on 150526, of surgical redo for
041398 - fundoplication. ref SDS 19 093H
041400 - ..
041401 - Today, the doctor asked if Doctor Lee is injecting steriods to
041402 - maintain LESV for swallowing?
041404 - ..
041405 - Advised that Doctor Lee has been injecting Triamcinolone steriods,
041406 - shown in case study, per above, ref SDS 0 XG6I, and referencing
041407 - Progress Notes, e.g., for most recent procedure on 151204 0800.
041408 - ref SDS 38 HU42
041409 -
041410 -
041411 -
041412 -
0415 -
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 43 XF6G.
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
050413 - ..
050414 - Customer....
050418 -
050419 - 1. LOCAL TITLE: GENERAL SURGERY CLINIC
050420 - STANDARD TITLE: SURGERY OUTPATIENT NOTE
050421 - DATE OF NOTE: JAN 19, 2016@14:03 ENTRY DATE: JAN 19, 2016@14:03:59
050422 - AUTHOR: LARSON,ANDREW R EXP COSIGNER:
050423 - URGENCY: STATUS: COMPLETED
050425 - ..
050426 - 2. General Surgery Follow up
050427 -
050428 - CC/ID: Mr Welch is a 70 year old man who is receiving treatment
050429 - following I & D of an infected hematoma, with LLE cellulitis
050430 - (on 9/23/15). The area had prior been treated with Hydrofera
050431 - Blue with BId wound changes, though this was discontinued on
050432 - 1/4 by wound care nursing when it was noted that the wound had
050433 - healed.
050435 - ..
050436 - 3. On another note, the pt has a history of achalasia (s/p
050437 - Laparoscopic Heller myotomy and Dor fundoplication in 2009 for
050438 - achalasia), for which he is currently being evaluated and
050439 - treated for a subsequent stricture by his GI doctor. Although
050440 - he receives symptomatic benefit from these dilations, he thinks
050441 - the frequency of dilations and steroid injections is too
050442 - infrequent (currently q6 months), whereas previously had been
050443 - q3-q4 months.
050445 - ..
050446 - O:
050447 - Vital Signs:
050448 - Height: 64.5 in [163.8 cm] (09/23/2015 15:32)
050449 - Weight: 192.8 lb [87.6 kg] (01/19/2016 13:43)
050450 - BMI: 32.6 (Obesity Level I)
050451 - BP: 145/81 (01/19/2016 13:43)
050452 - Resp: 16 (10/05/2015 08:40)
050453 - Pulse: 85 (01/19/2016 13:43)
050454 - O2 Sat: 1/19/16 13:43:08 O295
050455 - Pain: 0 (01/19/2016 13:43)
050457 - ..
050458 - 4. Exam: WDWN man in NAD. The wound over L lateral shin has now
050459 - completely healed, with scar tissue now replacing prior
050460 - granulation defect.
050462 - ..
050463 - 5. Impression: 70M with now healed soft tissue defect 2/2 infected
050464 - hematoma over L anterior shin, for which the patient no longer
050465 - needs to be followed in our clinic.
050467 - ..
050468 - 6. Additionally, the patient was requesting more information in
050469 - clinic today regarding futher surgical procedures for his
050470 - achalasia for which he is receiving dilations. Notably, given
050471 - his past surgical history, futher surgical intervention would
050472 - likely be a very substantial procedure which would include
050473 - esophagectomy. For that reason, since the patient describes
050474 - significant benefit from current dilations, we have recommended
050475 - that the patient continue to receive these, but on a more
050476 - frequent basis (every 3 months). We will have him follow up in
050477 - clinic in 6 months time following these more frequent dilations
050478 - for re-evaluation for surgery.
050480 - ..
050481 - EGD dilation procedures "every 3 months" to restore former favorable
050482 - LESV 18 mm from current 10 mm found during most recent dilation on
050483 - 151204, ref SDS 38 LC98, aligns with patient history dilating LESV
050484 - every 3 - 4 months from 2010 to 2013 that increased LESV 11 mm to 18
050485 - mm which then enabled normal swallowing the past 2 years...
050486 -
050487 - L E S V D I A L A T I O N
050488 - Months from - to
050489 - Interval Date mm mm
050490 - 8 151204 10 15.....triamcinolone.... ref SDS 38 HU42
050491 - 6 150421 16.5 18.....triamcinolone.... ref SDS 18 HU42
050492 - 6 141107 15 18.....triamcinolone.... ref SDS 16 I167
050493 - 6 140509 16.5 18...................... ref SDS 15 P680
050494 - 7 131115 16.5 18.....triamcinolone.... ref SDS 13 RZ45
050495 - 3 130416 18 18.....triamcinolone.... ref SDS 12 Y850
050496 - 4 130110 15 18.....triamcinolone.... ref SDS 11 Q333
050497 - 6 120925 15 18.....triamcinolone.... ref SDS 10 XB51
050498 - 4 120322 16.5 18...................... ref SDS 9 516N
050499 - 3 111115 16.5 18...................... ref SDS 8 IR57
050500 - 4 110819 15 16.5...triamcinolone.... ref SDS 7 J978
050501 - 3 110429 13 16.5...triamcinolone.... ref SDS 6 U23I
050502 - 3 110218 11 14.....triamcinolone.... ref SDS 5 AA5O
050503 - 4 101210 11 14...................... ref SDS 4 H347
050504 - 5 100827 11 15...................... ref SDS 3 JE6X
050505 - 3 100305 11 15...................... ref SDS 2 WR6L
050506 - 091216 Heller Myotomy Fundoplication ref SDS 1 KE9U
050508 - ..
050509 - 7. I have discussed the patient with my attending physician, Dr
050510 - Stewart, who agrees with my assessment and plan.
050512 - ..
050513 - 8. Current medications reviewed with patient/caregiver and
050514 - reconciliation of medications related to today's visit
050515 - completed, including non-VA medications and discrepancies, if
050516 - identified, were addressed. Medication changes and the
050517 - importance of medication management were reviewed with the
050518 - patient/caregiver today based on individual needs.
050519 - Patient/caregiver acknowledged understanding of instructions as
050520 - stated. An updated list of reconciled medications has been
050521 - provided to the patient/caregiver.
050523 - ..
050524 - Would help for Progress Notes to list medications correlated with list
050525 - submitted with the agenda for the meeting on 160118 0124. ref SDS 47
050526 - X667
050527 -
050528 - /es/ ANDREW R LARSON
050529 - PGY1
050530 - Signed: 01/19/2016 22:52
050531 -
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0506 -