CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 37 0000. ref SDS 31 0000.
040502 -
040503 -
040504 -
040505 -
040506 - [On 160505 1715 letter to medical team cites Doctor Simpson
040507 - concern elevated CRP-HS lab, ref SDS 44 J05G, discussed
040508 - fall on 160501, which later caused severe bruise that could
040509 - have elevated CRP-HS 20 by 300% above range. ref SDS 44
040510 - J07Q Recommend waiting for several weeks, until bruise
040511 - resolves to re-test CRP-HS lab. ref SDS 44 J074
040512 -
040513 -
040515 - ..
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 14 BV4I
041009 - ..
041010 - On 131125 0005 research indicates Atorvastatin 10 Ezetimibe 10
041011 - Increase HDL 5% TG 30% Lower LDL-C 50%. ref SDS 15 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 15 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 15 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 15 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 15 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 15 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 15 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 15 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 17 JZ4O, which is the healthiest condition for CVD
041063 - patients, shown by research on 131125 0005. ref SDS 15 FI3G
041065 - ..
041066 - On 151028 1000 Doctor Simpson advised he has received no
041067 - correspondence from the patient. This indicates correspondence is
041068 - incorrectly addressed, or that the VA is intercepting the doctor's
041069 - mail. ref SDS 31 NV5I
041070 -
041071 -
041072 -
041074 - ..
0411 -
0412 -
0413 - Progress
0414 -
041401 - Agenda for meeting...
041402 -
041403 - 1. Lab results...
041404 -
041405 - 1. HDL............................. VA 57
041406 - 2. Triglycerides................... VA 55
041407 - 3. LDL-C........................... VA 128
041408 - 4. Total Cholesterol............... VA 196
041410 - ..
041411 - Doctor Simpson reviewed lab results for cholesterol panel yesterday on
041412 - 160503 1130. ref SDS 42 U45J
041414 - ..
041415 - He was was pleased HDL 57 has remained elevated.
041417 - ..
041418 - HDL 57 declined 22% from HDL 73 on 160131, ref SDS 36 U45J because
041419 - hiking was reduced 90% by injuries the past 4 months, since meeting on
041420 - 160203.
041422 - ..
041423 - Last Friday, injuries healed sufficiently to resume hiking...
041424 -
041425 - 160429....................... 11
041426 - 160430....................... 11
041427 - 160501....................... 21
041428 - 160502....................... 22
041429 - 160503....................... 15
041431 - ..
041432 - Total 5 days................. 80
041434 - ..
041435 - This raised HDL mid-40s (likely) to 57 for lab on 160503. Expect if
041436 - work plan was implemented to do the 2nd lap yesterday, increasing
041437 - mileage to 26 on 160503, and total 91 miles for the 5 days, had a good
041438 - chance of reaching patient care goal - HDL 60+ on 160503.
041439 -
041440 -
041441 -
041443 - ..
041444 - CRP-HS Elevated 300% Possible Signal Coronary Related Event or Error
041445 -
041446 - Doctor Simpson noted with alarm that CRP-HS 20.6 is 300% above the
041447 - range 0.2 - 7.5, it is 500% above the median. ref SDS 42 126H
041449 - ..
041450 - He explained Cardiology tracks CRP-HS to assess inflammation of the
041451 - artery system, since it signals impending severe coronary events, like
041452 - myocardial infarction (heart attack), stroke, thrombosis. He feels it
041453 - must be an erroneous lab, since it conflicts with the lab yesterday on
041454 - 160503, showing favorable lipids, ref SDS 42 U45J, and further listed
041455 - above. ref SDS 0 NV5I Adverse implications of CRP-HS 20.6 further
041456 - conflicts with CCTA radiology test on 151019, per above. ref SDS 0
041457 - XM7O
041459 - ..
041460 - Doctor Simpson discussed ordering another lab to verify CRP-HS.
041462 - ..
041463 - VA lab guidance says in part...
041464 -
041465 - The CDC and AHA recommnd the following guidelines based on two
041466 - test results, two weeks apart in metabolically stable patients.
041467 - ref SDS 42 127G
041468 -
041469 - [...below in this record on 160504 1000 Progress Notes say
041470 - CRP-HS will be checked in lab ordered for September.
041471 - ref SDS 0 5R6K
041473 - ..
041474 - [On 160505 1715 letter to medical team cites Doctor
041475 - Simpson's concern elevated CRP-HS lab, ref SDS 44 J05G,
041476 - discussed fall on 160501, which later caused severe bruise
041477 - on 160502, that could have elevated CRP-HS 20 by 300% above
041478 - range. ref SDS 44 J07Q Recommend waiting for several
041479 - weeks, until bruise resolves to re-test CRP-HS lab.
041480 - ref SDS 44 J074
041481 -
041483 - ..
041484 - 2. CCTA on 151019, amended findings filed on 160113, ref SDS 35
041485 - A85F, says in part...
041487 - ..
041488 - No significant calcified plaque is seen in the bypass grafts.
041489 - All the bypass grafts are opacified with contrast without
041490 - evidence for filling defect or wall calcifications. ref SDS 29
041491 - SU62
041493 - ..
041494 - No calcification is seen in the aortic wall in the visualized
041495 - portions of the thoracic aorta. No ostial calcifications at
041496 - the origins of great vessels from the aortic arch. ref SDS 29
041497 - SU67
041499 - ..
041500 - Doctor Simpson said today these favorable findings together with
041501 - continuing favorable lipid labs, per above, ref SDS 0 NV5I, indicate
041502 - response to treatment with extended endurance exercise, so there is no
041503 - reason for him to continue seeing me as a cardiology patient. In
041504 - effect VA care has cured the patient of atherosclerosis.
041506 - ..
041507 - We decided to continue patient care and monitoring for at least
041508 - another cycle in 4 months, schedule in October after Half Dome in
041509 - September.
041511 - ..
041512 - The doctor commented that he enjoys working with patients, who
041513 - responds well to treatment, despite disagreements about taking aspirin
041514 - and minimal dose of statin drugs, rather standard dose for CAD
041515 - patients.
041517 - ..
041518 - After the meeting, the scheduling staff said the VA computer schedule
041519 - software cannot enter meetings over 3 months out.
041521 - ..
041522 - VA will submit notice for the patient to request meeting with
041523 - Cardiology.
041524 -
041525 -
041527 - ..
041528 - 3. Atorvastatin 10 mg Ezetemibe 10 mg every other day.
041530 - ..
041531 - Doctor Simpson asked about current dose of statin medications?
041533 - ..
041534 - We reviewed the record resuming prescription for Atorvastatin 10 mg
041535 - with Ezetimibe 10 mg daily, which was discussed and agreed during the
041536 - meeting on 151028 1000. ref SDS 31 U74F
041538 - ..
041539 - During the meeting on 160203, Doctor Simpson reduced statin treatment
041540 - 50% - so now taking Atorvastatin 10 mg and Ezetimibe 10 mg every other
041541 - day, ref SDS 37 UV5M, based on favorable labs and CCTA finding no
041542 - evidence of atherosclerosis in active circulatory system, per above.
041543 - ref SDS 0 XM7O This does has been better tolerated reducing adverse
041544 - side effects of dizziness and frequent urination.
041546 - ..
041547 - As a result, decided to continue taking Atorvastatin 10 mg and
041548 - Ezetimibe 10 mg every other day for another cycle, with objective for
041549 - further reducing statin treatment to further reduce frequent urination
041550 - and dizziness side effects.
041551 -
041553 - ..
041554 - 4. Hiking suffered fall due to balance problems
041555 -
041556 - On 160501, after hiking usual 11 mile route in the morning,
041557 - hiked another 9 miles through mountainous terrain in Crystal
041558 - Rock Park, Walnut Creek. Suffered another fall crossing a very
041559 - shallow stream stepping across on rocks and logs, reported in
041560 - case study on 140101 0600. ref SDS 16 O85F
041562 - ..
041563 - Fall in this case seems similar to falling on Half Dome hike
041564 - last year on 150916 0535. ref SDS 20 O87H
041566 - ..
041567 - Both occurred from losing balance.
041569 - ..
041570 - Doctor Simpson commented that losing balance occurs from dizziness
041571 - where there is a sensation the room is spinning, and commonly called
041572 - "vertigo." He seemed to indicate this occurs when people are
041573 - sitting down, standing still, or laying in bed.
041575 - ..
041576 - He may have used the term "BPPV".
041577 -
041578 - [On 160513, Lauren called and discussed again falling can
041579 - be related to BPPV neurology condition. Research at that
041580 - time found BPPV = "Benign paroxysmal positional vertigo"
041581 - and occurs when calcified crystals in either or both
041582 - vestibular chambers somehow move into the semicircular
041583 - canals that maintain balance. ref SDS 45 CV4L
041585 - ..
041586 - Advised there has never been "spinning" sensation while sitting or
041587 - standing. Over the past 10 - 15 years on a few occasions there has
041588 - been a "spinning" sensation while laying down and turning the head
041589 - left or right, getting up from bed, bending over to adjust cables on a
041590 - computer - that kind of activity. Have no recent memory of this
041591 - occurring.
041593 - ..
041594 - Explained on Sunday, there was no spinning sensation nor dizziness
041595 - associated or proceeding the fall. I suddenly realized I was near to
041596 - hitting the ground.
041597 -
041598 - [On 160504 1030 reported fall on Sunday, to Lauren during
041599 - meeting for Primary Care, ref SDS 43 JN3J; Lauren cited
041600 - possible BPPV, and performed Neurology test - passed
041601 - everything, ref SDS 43 9L7K, including Romberg's balanace
041602 - "sway" test. ref SDS 43 WZ40
041604 - ..
041605 - [On 160505 1715 letter to medical team reports falling on
041606 - 160501, and last year on 160916, were not accompanied by
041607 - dizziness. These were sway-related falls. ref SDS 44 J080
041608 - Surgery is asked about resolution of calcium crystals in
041609 - semicircle canals that disrupt balanc. ref SDS 44 J08S
041610 -
041612 - ..
041613 - 5. Current Medications
041615 - ..
041616 - Doctor Simpson asked for list of current medications? Advised that
041617 - he can get a list of daily medications in case study on 140101 0600.
041618 - ref SDS 16 QJ5I
041620 - ..
041621 - The doctor wrote a list of current medications to update VA records...
041622 -
041623 - Famotidine.................. 20 mg twice per day (morning and night)
041624 - Co-q10 Ubiquinol............ 20 ml daily
041625 - Naproxen (Aleve)............ 400 mg before hiking
041626 - Glucosamine Chondroitin..... 100 ml before hiking
041627 - Omeprazole.................. 20 mg every other day
041628 - Atorvastatin................ 10 mg every other day
041629 - Ezetimibe................... 10 mg every other day
041630 - Mintox (Mylanta)............ 30 ml daily
041631 -
041632 - [...below on 160504 1000 VA Progress Notes do not list
041633 - Famotidine 20 mg twice per day, do not list Atorvastatin 10
041634 - mg and Ezitimibe 10 mg both every other day, nor Omperpaole
041635 - 20 mg everyother day; CoQ10 is not listed, and Glucosamine
041636 - Chondroitin is not listed. ref SDS 0 QZ7L
041637 -
041639 - ..
041640 - 6. HDL Atherosclerosis Vascular Senescence Cognition
041642 - ..
041643 - Briefly reviewed research on 160424 indicating elevated HDL correlates
041644 - with longevity, e.g., centenarians, ref SDS 41 WU5I, under a theory
041645 - that cellular senescence occurs with the rise of atherosclerosis that
041646 - rises with age. ref SDS 40 W66M Elevated HDL may also help
041647 - prevent/delay decline of cognition with age. ref SDS 41 NX6I
041649 - ..
041650 - Reporting last month on 160405, that major drug companies have
041651 - abandoned studies to artificially raise HDL with medications, because
041652 - these current crop of drugs has not extended longevity, 160405 1305,
041653 - ref SDS 38 J47N, seems to indicate people have invested billions of
041654 - dollars to benefit from elevated HDL.
041655 -
041657 - ..
041658 - Doctor Simpson said this is not his field. He indicated no awareness
041659 - of colleagues or others at UCSF working in this field.
041660 -
041661 -
041663 - ..
041664 - 7. Hoka new shoe models fit worse that prior models.
041666 - ..
041667 - Doctor Simpson asked about buying new Hoka shoes, continuing
041668 - discussion on 151014 0900. ref SDS 27 E23O
041670 - ..
041671 - His Hoka shoes have worn out. He tried to buy new shoes to replace
041672 - the old ones, and was told Hoka no longer makes the shoes he has that
041673 - work well. He needs a wider than normal shoe. Hoka offered him new
041674 - model shoes. The doctor tried these and found they are inadequate.
041676 - ..
041677 - Explained similar experience attempting to replace 7 pair of Hoka
041678 - Stinson Lite shoes, reported recently on 160423 0804. ref SDS 39 129N
041679 - Hoka discontinued Stinson Lite shoes. Tried 4 different models, and
041680 - they all cause wounds that need specialized dressings, reported for
041681 - example yesterday on 160503, see case study 140101 0600. ref SDS 16
041682 - EF5M
041684 - ..
041685 - [On 160513 1100 meeting with Primary Care, Lauren could not
041686 - order medical supplies needed to treat wounds wearing new
041687 - Hoka Stinson 3 shoes, where Hoka stopped making shoes that
041688 - worked well the past 2 years. Lauren made referral to
041689 - Wound Care for supplies and consult on dressings to prevent
041690 - injuries with new shoes. ref SDS 45 ER4I,
041692 - ..
041693 - Thanked Doctor Simpson for outstanding care.
041694 -
041695 -
041696 -
041697 -
041698 -
041699 -
0417 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Medical Chart Progress Notes for Cardiology Meeting 160504
050403 - Progress Notes Cardiology Meeting 160504 Doctor Simpson
050404 - Doctor Simpson Progress Notes Cardiology Meeting 160504
050405 -
050406 - Follow up ref SDS 37 P97K, ref SDS 32 868G.
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 -
050423 -
050424 -
050425 - 1. Date/Time: 04 May 2016 @ 1044
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: 04 May 2016 @ 1213
050432 - ..
050433 - 2. LOCAL TITLE: CARDIOLOGY CLINIC ATTENDING NOTE (MED)
050434 - STANDARD TITLE: CARDIOLOGY ATTENDING NOTE
050435 - DATE OF NOTE: MAY 04, 2016@10:44 ENTRY DATE: MAY 04, 2016@10:44:34
050436 - AUTHOR: SIMPSON,PAUL C EXP COSIGNER:
050437 - URGENCY: STATUS: COMPLETED
050439 - ..
050443 - ..
050444 - 3. Most Recent VITAL SIGNS:
050445 - Height: 64.5 in [163.8 cm] (09/23/2015 15:32)
050446 - Weight: 191 lb [86.8 kg] (05/04/2016 09:47)
050447 - BMI: 32.3 (Obesity Level I)
050448 - Temp: 97.9 F [36.6 C] (04/18/2016 14:17)
050449 - Pulse: 69 (05/04/2016 09:47)
050451 - ..
050452 - Comments:
050454 - ..
050455 - Resp: 17 (04/18/2016 14:17)
050456 - BP: 138/72 (05/04/2016 09:47)
050458 - ..
050459 - O2 Sat: 5/4/16 09:47:05 O2:98
050461 - ..
050462 - 4. ID/CC:
050463 -
050464 - 71 swm from concord returns to routine f/u CAD sp CABG and CRFs.
050466 - ..
050467 - 5. CARD PROBLEMS:
050468 -
050469 - 1. CAD sp CABG here 10-22-09 (LIMA, SVG diag, ramus, PDA)
050470 -
050471 - last TTE here 10-26-09 wnl
050472 - last seen CT Surg 11-19-09, never cards
050473 - cor CTA 10-19-15 all grafts open (by my discn w radiol, some lumps
050474 - proximal left SVGs, ca score >1000)
050476 - ..
050477 - Reference to "...dscn w radiol, some lumps" relates to meeting on
050478 - 151028. At that time, Doctor Simpson explained he asked the
050479 - radiologist about "some gray stuff" they observed together during a
050480 - joint examination of the CT scan file. Doctor Simpson suspected this
050481 - might be accumulating plaque in the active artial blood vessel system.
050482 - Doctor Simpson seemed to say that the the radiologist indicated it
050483 - could be. ref SDS 31 U27N
050485 - ..
050486 - Doctor Simpson further adivsed on 151028, that plaque begins to
050487 - accumulate in bypass grafts within 2 years after CABG. ref SDS 31 5L98
050489 - ..
050490 - On 151203 patient met with radiologist who advised that CT test on
050491 - 151019 shows no evidence of atheroscloerotis plauqes nor blockages of
050492 - any kind in the active circulatory system visible in the scan file.
050493 - ref SDS 33 SZ5F
050495 - ..
050496 - On 160104 0855 Doctor Jha, attending physician for this CCTA imaging
050497 - study, advised that standard of practice for radiology is to report
050498 - any and all blockages of any kind observable in CCTA scan imaging; so,
050499 - in this case, since none are reported, the CCTA test on 151019, can
050500 - correctely be interpretted to mean there are no blockages, plaques,
050501 - stenosis of any kind evident from the scan file record. ref SDS 34
050502 - 054G
050504 - ..
050505 - Progress Notes for 160504 continue...
050506 -
050507 - CTA addendum states: Coronary calcium score is calculated
050508 - to be 1360.
050509 -
050510 - No significant calcified plaque is seen in the bypass
050511 - grafts. All the bypass grafts are opacified with
050512 - contrast without evidence for filling defect or wall
050513 - calcifications.
050515 - ..
050516 - No calcification is seen in the aortic wall in the
050517 - visualized portions of the thoracic aorta. No ostial
050518 - calcifications at the origins of great vessels from
050519 - the aortic arch.
050521 - ..
050522 - More Ca++ in proximal bypassed vessels w/o blood flow not
050523 - unexpected.
050525 - ..
050526 - 2. hyperlipidemia LDL 170 12-14-09; lately ok, then bad again
050527 - off statin, then better on low dose atorva 10 plus ezet; qd
050528 - better than qod
050530 - ..
050531 - 3. Overwt/obesity (BMI ~30); wt gain lately 2016.
050533 - ..
050534 - 4. Statin SEs: freq urination, dry feet, pain left arm
050535 -
050537 - ..
050538 - Progress Notes for 160504 continue...
050539 -
050540 - 6. ASSESS
050541 -
050542 - 1. clinically doing excellent
050543 -
050544 - 2. wt is up likely b/c can't hike as much d/t MSK issues
050546 - ..
050547 - This aligns with report during the meeting that hiking down 90%, since
050548 - prior meeting on 160203, per above. ref SDS 0 RM8L
050550 - ..
050551 - Progress Notes for 160504 continue...
050552 -
050553 - 3. LDL up a bit (128 v 96 in feb 16) on sl less statin (qod),
050554 - HS-CRP is surprisingly high (~21) not sure why ? right knee
050555 -
050556 - [On 160505 1715 letter to medical team cites Doctor
050557 - Simpson's concern elevated CRP-HS lab, ref SDS 44 J05G,
050558 - discussed fall on 160501, which later caused severe bruise
050559 - on 160502, that could have elevated CRP-HS 20 by 300% above
050560 - range. ref SDS 44 J07Q Recommend waiting for several
050561 - weeks, until bruise resolves to re-test CRP-HS lab.
050562 - ref SDS 44 J074
050564 - ..
050565 - 4. c/o balance problems he thinks might be middle ear, but it
050566 - is not vertigo; seems a little ortho dizziness.
050567 -
050568 - 5. he is NOT taking asa and does not wish to
050569 -
050571 - ..
050572 - PLAN:
050573 -
050574 - 1. We went over my concerns re statin and asa, he wishes to
050575 - cont as is.
050576 -
050577 - 2. He hopes to be able to get back to hiking as before
050579 - ..
050580 - 3. We went over healthy lifestyle in general
050582 - ..
050583 - 4. I will see again after he tries a yosemite half-dome hike in
050584 - oct
050586 - ..
050587 - 5. I will put repeat labs hs-cpr etc for sept.
050589 - ..
050590 - This work plan aligns with understandings during the meeting today,
050591 - per above. ref SDS 0 TA6G
050592 -
050593 - [On 160505 1715 letter to medical team cites Doctor
050594 - Simpson's concern elevated CRP-HS lab, ref SDS 44 J05G,
050595 - discussed fall on 160501, which later caused severe bruise
050596 - on 160502, that could have elevated CRP-HS 20 by 300% above
050597 - range. ref SDS 44 J07Q Recommend waiting for several
050598 - weeks, until bruise resolves to re-test CRP-HS lab.
050599 - ref SDS 44 J074
050601 - ..
050602 - Progress Notes for 160504 continue...
050603 -
050604 - 7. HPI:
050605 -
050606 - doing well, but gained some wt since less able to hike dt
050607 - various foot and knee issues.
050609 - ..
050610 - Aligns with discussion during the meeting, per above. ref SDS 0 RM8L
050612 - ..
050613 - Progress Notes for 160504 continue...
050614 -
050615 - no cv sxs.
050616 -
050617 - gi ok
050618 -
050620 - ..
050621 - 8. SH:
050622 -
050623 - 1. lives concord
050624 -
050625 - 2. single has gf
050626 -
050627 - 3. wife of many years died of breast ca a few yrs ago
050629 - ..
050630 - 4. Gets up 3-6 am often to walk, bed early am, so not much sleep.
050631 -
050632 - 5. one meal a day in evening, but healthy (fish, avocados,
050633 - vegs).
050635 - ..
050636 - Patient exercise times and mileage, diet - what is eaten for each
050637 -
050638 -
050640 - ..
050641 - 9. OTHER:
050642 -
050643 - 1. achalasia sp ops
050644 - 2. LLE hematoma w cellulitis sp fall (adm here 9-23 to 9-25-15)
050645 - 3. recent fx R radius (same fall), may16 notes balance issues
050646 -
050648 - ..
050649 - 10. ASSESS:
050650 -
050651 - 1. clinically doing excellent
050652 -
050653 - 2. wt is up likely b/c can't hike as much d/t MSK issues
050655 - ..
050656 - This aligns with report during the meeting that hiking down 90%, since
050657 - prior meeting on 160203, per above. ref SDS 0 RM8L
050659 - ..
050660 - Progress Notes for 160504 continue...
050661 -
050662 - 3. LDL up a bit (128 v 96 in feb 16) on sl less statin (qod),
050663 - HS-CRP is surprisingly high (~21) not sure why ? right knee
050664 -
050665 - [On 160505 1715 letter to medical team cites Doctor
050666 - Simpson's concern elevated CRP-HS lab, ref SDS 44 J05G,
050667 - discussed fall on 160501, which later caused severe bruise
050668 - on 160502, that could have elevated CRP-HS 20 by 300% above
050669 - range. ref SDS 44 J07Q Recommend waiting for several
050670 - weeks, until bruise resolves to re-test CRP-HS lab.
050671 - ref SDS 44 J074
050673 - ..
050674 - 4. c/o balance problems he thinks might be middle ear, but it
050675 - is not vertigo; seems a little ortho dizziness.
050676 -
050677 - 5. he is NOT taking asa and does not wish to
050678 -
050680 - ..
050681 - PLAN:
050682 -
050683 - 1. We went over my concerns re statin and asa, he wishes to
050684 - cont as is.
050685 -
050686 - 2. He hopes to be able to get back to hiking as before
050688 - ..
050689 - 3. We went over healthy lifestyle in general
050691 - ..
050692 - 4. I will see again after he tries a yosemite half-dome hike in
050693 - oct
050695 - ..
050696 - 5. I will put repeat labs hs-cpr etc for sept.
050698 - ..
050699 - This work plan aligns with understandings during the meeting today,
050700 - per above. ref SDS 0 TA6G
050701 -
050702 - [On 160505 1715 letter to medical team cites Doctor
050703 - Simpson's concern elevated CRP-HS lab, ref SDS 44 J05G,
050704 - discussed fall on 160501, which later caused severe bruise
050705 - on 160502, that could have elevated CRP-HS 20 by 300% above
050706 - range. ref SDS 44 J07Q Recommend waiting for several
050707 - weeks, until bruise resolves to re-test CRP-HS lab.
050708 - ref SDS 44 J074
050710 - ..
050711 - Progress Notes for 160504 continue...
050712 -
050713 - 11. HPI:
050714 -
050715 - doing well, but gained some wt since less able to hike dt
050716 - various foot and knee issues.
050718 - ..
050719 - Aligns with discussion during the meeting, per above. ref SDS 0 RM8L
050721 - ..
050722 - Progress Notes for 160504 continue...
050723 -
050724 - no cv sxs.
050725 -
050726 - gi ok
050727 -
050729 - ..
050730 - 12. SH:
050731 -
050732 - 1. lives concord
050733 -
050734 - 2. single has gf
050735 -
050736 - 3. wife of many years died of breast ca a few yrs ago
050738 - ..
050739 - 4. Gets up 3-6 am often to walk, bed early am, so not much sleep.
050740 -
050741 - 5. one meal a day in evening, but healthy (fish, avocados,
050742 - vegs).
050744 - ..
050745 - Patient exercise times and mileage, diet - what is eaten for each
050746 - meal, medications - times, amount and totals to date - and vitals can
050747 - be viewed on the Internet by medical team in case study on 140101
050748 - 0600. ref SDS 16 QJ5I The format evolved over the years, but is
050749 - generally clear. This record is maintained daily, and updated from
050750 - time to time on the Internet.
050752 - ..
050753 - Progress Notes for 160504 continue...
050754 -
050755 - Active Medications:
050756 -
050757 - 1. AMMONIUM LACTATE 12% LOTION APPLY LOTION TOPICALLY
050758 - EVERY DAY TO DRY SKIN
050759 - 2. ATORVASTATIN CALCIUM 20MG TAB TAKE ONE-HALF TABLET taking qod
050760 - ORALLY AT BEDTIME FOR CHOLESTEROL
050761 - 3. CLOTRIMAZOLE 1% TOP CREAM APPLY CREAM TOPICALLY TWICE
050762 - A DAY UNDER AFFECTED TOE
050763 - 4. EZETIMIBE 10MG TAB TAKE ONE TABLET ORALLY EVERY DAY taking qod
050764 - 5. FAMOTIDINE 20MG TAB TAKE ONE TABLET ORALLY AT BEDTIME taking bid
050765 - FOR STOMACH
050766 - 6. GAUZE PAD 4IN X 4IN 12-PLY STERILE USE GAUZE AS
050767 - DIRECTED TO COVER WOUND PACKING.
050768 - 7. KERLIX 4.5IN STERILE USE BANDAGE AS DIRECTED TO WRAP
050769 - LOOSELY AROUND WOUND.
050770 - 8. OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE ORALLY TWICE taking 1 qod
050771 - A DAY
050772 - 9. TAPE,MICROPORE 2IN 3M #1530-2 USE TAPE AS DIRECTED
050774 - ..
050775 - During the meeting today, Doctor Simpson asked for current mediations.
050776 - This included CoQ10, Neproxen, Glucosamine Chondroitin, per above.
050777 - ref SDS 0 OV6P
050779 - ..
050780 - Progress Notes for 160504 continue...
050781 -
050782 - 13. Computerized Problem List is the source for the following:
050783 -
050784 - 1. History of coronary artery bypass grafting, 10/14/2015
050785 -
050786 - Onset 10/00/2009
050787 - SFVA LIMA, SVGs diag, ramus, PDA
050789 - ..
050790 - 2. Hyperlipidemia 10/14/2015
050791 - 3. Body mass index 30+ - obesity 10/14/2015
050792 - 4. Chronic ischemic heart disease 10/14/2015
050793 - 5. Esophageal Achalasia * (ICD-9-CM 530.0) 12/08/2009
050795 - ..
050796 - 14. EXAM
050797 -
050798 - 1. vs above ok x wt up abt 15 lbs from last fall
050799 - 2. looks v well, younger than age
050800 - 3. shorts sneakers
050801 - 4. jvp nl, ajr neg
050802 - 5. car no bruit
050803 - 6. chest clear
050804 - 7. hrt reg strong 1/6 sm lsb
050805 - 8. abd sl tense but no mass, bruit, tenderness
050806 - 9. exo no edema
050807 - 10. no signs abnl balance
050809 - ..
050810 - 15. Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050811 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050813 - ..
050814 - Report Released Date/Time: May 03, 2016@14:00
050815 - Provider: LUDWIG,ALISON M
050816 - Specimen: PLASMA. CH 0503 697
050817 - Specimen Collection Date: May 03, 2016@11:45
050818 - Test name Result units Ref. range Site Code
050819 - EGFR 61 mL/min Ref: >=60 [662]
050820 - SODIUM 141 mmol/L 135 - 145 [662]
050821 - POTASSIUM 4.8 mmol/L 3.3 - 4.8 [662]
050822 - CHLORIDE 103 mmol/L 101 - 112 [662]
050823 - CARBON DIOXIDE 27 mmol/L 24 - 32 [662]
050824 - ANION GAP 11 mmol/L 5 - 20 [662]
050825 - UREA NITROGEN 34 H mg/dL 10 - 24 [662]
050826 - CREATININE 1.18 mg/dL 0.6 - 1.3 [662]
050827 - GLUCOSE 104 mg/dl 65 - 115 [662]
050828 - CALCIUM 9.1 mg/dL 8.5 - 10.5 [662]
050829 -
050830 -
050832 - ..
050833 - 16. Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050834 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050836 - ..
050837 - Report Released Date/Time: May 03, 2016@14:11
050838 - Provider: SIMPSON,PAUL C
050839 - Specimen: PLASMA. CH 0503 696
050840 - Specimen Collection Date: May 03, 2016@11:45
050841 - Test name Result units Ref. range Site Code
050842 - CRP-HS 20.6 H mg/L 0.2 - 7.5 [662]
050843 - Eval: Inflammation reference range: 0.2 - 7.5 mg/L
050844 - Eval: For assessment of risk for cardiovascular disease in adults,
050845 - Eval: the CDC and AHA recommend the following guidelines based on two
050846 - Eval: test results, two weeks apart in metabolically stable patients:
050847 - Eval:
050848 - Eval: Cardiovascular Disease Risk CRP-HS mg/L
050849 - Eval: Low......................<1.0
050850 - Eval: Average......................1.0-3.0
050851 - Eval: High.......................>3.0 - 10.0
050852 - Eval: Indeterminate...................>10
050853 - Eval:
050854 - Eval: If CRP-HS level is >10 mg/L, the patient should be evaluated
050855 - Eval: for possible sources of infection or inflammation. Repeat CRP-HS
050856 - Eval: may also be appropriate.
050857 - CHOLESTEROL 196 mg/dl 100 - 240 [662]
050858 - TRIGLYCERIDE 55 mg/dl 10 - 190 [662]
050859 - HIGH DENSITY LIPOPROT (HDL) 57 mg/dl Ref: >=35 [662]
050860 - Eval: HDL <35 is associated with increased risk of CAD.
050861 - LDL CHOL(Calculated) 128 mg/dl Ref: <=131 [662]
050862 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050863 -
050865 - ..
050866 - 17. Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050867 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050869 - ..
050870 - Report Released Date/Time: May 03, 2016@13:57
050871 - Provider: RETTBERG,LAUREN B
050872 - Specimen: PLASMA. EIA 0503 127
050873 - Specimen Collection Date: May 03, 2016@11:45
050874 - Test name Result units
050875 - Ref. range Site Code
050876 - HEPATITIS C ANTIBODY NEG Ref: NEG [662]
050877 -
050879 - ..
050880 - 18. Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050881 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050883 - ..
050884 - Report Released Date/Time: Feb 02, 2016@14:35
050885 - Provider: RAO,MADHU N
050886 - Specimen: PLASMA. CH 0202 1047
050887 - Specimen Collection Date: Feb 02, 2016@13:34
050888 - Test name Result units Ref. range Site Code
050889 - EGFR 64 mL/min Ref: >=60 [662]
050890 - SODIUM 144 mmol/L 135 - 145 [662]
050891 - POTASSIUM 5.0 H mmol/L 3.3 - 4.8 [662]
050892 - CHLORIDE 108 mmol/L 101 - 112 [662]
050893 - CARBON DIOXIDE 27 mmol/L 24 - 32 [662]
050894 - ANION GAP 9 mmol/L 5 - 20 [662]
050895 - UREA NITROGEN 24 mg/dL 10 - 24 [662]
050896 - CREATININE 1.13 mg/dL 0.6 - 1.3 [662]
050897 - GLUCOSE 104 mg/dl 65 - 115 [662]
050898 - CALCIUM 9.1 mg/dL 8.5 - 10.5 [662]
050899 - PHOSPHORUS 3.2 mg/dL 2.5 - 4.5 [662]
050900 - ALBUMIN 4.3 gm/dL 3.3 - 5.2 [662]
050901 - PROTEIN, TOTAL 6.9 g/dL 6.0 - 8.5 [662]
050902 - ALKALINE PHOSPHATASE 82 U/L 40 - 125 [662]
050903 - SGOT 33 U/L 5 - 35 [662]
050904 - SGPT 22 U/L 7 - 56 [662]
050905 - BILIRUBIN, TOTAL 2.2 H mg/dL 0.1 - 1.2 [662]
050906 - BILIRUBIN, DIRECT 0.2 mg/dL 0.1 - 0.5 [662]
050907 - CHOLESTEROL 177 mg/dl 100 - 240 [662]
050908 - TRIGLYCERIDE 61 mg/dl 10 - 190 [662]
050909 - HIGH DENSITY LIPOPROT (HDL) 69 mg/dl Ref: >=35 [662]
050910 - Eval: HDL <35 is associated with increased risk of CAD.
050911 - LDL CHOL(Calculated) 96 mg/dl Ref: <=131 [662]
050912 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050913 -
050914 -
050916 - ..
050917 - 19. Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050918 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050920 - ..
050921 - Report Released Date/Time: Feb 02, 2016@14:28
050922 - Provider: SIMPSON,PAUL C
050923 - Specimen: BLOOD. HE 0202 335
050924 - Specimen Collection Date: Feb 02, 2016@13:34
050925 - Test name Result units Ref. range Site Code
050926 - WBC 9.40 K/cmm 4.8 - 10.8 [662]
050927 - RBC 5.51 M/cmm 4.7 - 6.1 [662]
050928 - HEMOGLOBIN 15.3 g/dl 14 - 18 [662]
050929 - HEMATOCRIT 47.6 % 42 - 52 [662]
050930 - MCV 86.4 fL 80 - 100 [662]
050931 - MCH 27.7 pg 27 - 32 [662]
050932 - MCHC 32.1 gm/dL 32 - 36 [662]
050933 - PLATELET COUNT 325 K/cmm 140 - 450 [662]
050934 -
050936 - ..
050937 - 20. Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050938 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050940 - ..
050941 - Report Released Date/Time: Feb 02, 2016@14:51
050942 - Provider: SIMPSON,PAUL C
050943 - Specimen: PLASMA. CH 0202 1046
050944 - Specimen Collection Date: Feb 02, 2016@13:34
050945 - Test name Result units Ref. range Site Code
050946 - CRP-HS 3.8 mg/L 0.2 - 7.5 [662]
050947 - Eval: Inflammation reference range: 0.2 - 7.5 mg/L
050948 - Eval: For assessment of risk for cardiovascular disease in adults,
050949 - Eval: the CDC and AHA recommend the following guidelines based on two
050950 - Eval: test results, two weeks apart in metabolically stable patients:
050951 - Eval:
050952 - Eval: Cardiovascular Disease Risk CRP-HS mg/L
050953 - Eval: Low......................<1.0
050954 - Eval: Average......................1.0-3.0
050955 - Eval: High.......................>3.0 - 10.0
050956 - Eval: Indeterminate...................>10
050957 - Eval:
050958 - Eval: If CRP-HS level is >10 mg/L, the patient should be evaluated
050959 - Eval: for possible sources of infection or inflammation. Repeat CRP-HS
050960 - Eval: may also be appropriate.
050961 - EGFR 65 mL/min Ref: >=60 [662]
050962 - SODIUM 146 H mmol/L 135 - 145 [662]
050963 - POTASSIUM 5.0 H mmol/L 3.3 - 4.8 [662]
050964 - CHLORIDE 109 mmol/L 101 - 112 [662]
050965 - CARBON DIOXIDE 28 mmol/L 24 - 32 [662]
050966 - ANION GAP 9 mmol/L 5 - 20 [662]
050967 - UREA NITROGEN 23 mg/dL 10 - 24 [662]
050968 - CREATININE 1.11 mg/dL 0.6 - 1.3 [662]
050969 - GLUCOSE 105 mg/dl 65 - 115 [662]
050970 - CALCIUM 9.4 mg/dL 8.5 - 10.5 [662]
050971 - ALBUMIN 4.4 gm/dL 3.3 - 5.2 [662]
050972 - PROTEIN, TOTAL 7.1 g/dL 6.0 - 8.5 [662]
050973 - ALKALINE PHOSPHATASE 85 U/L 40 - 125 [662]
050974 - SGOT 33 U/L 5 - 35 [662]
050975 - SGPT 24 U/L 7 - 56 [662]
050976 - BILIRUBIN, TOTAL 2.0 H mg/dL 0.1 - 1.2 [662]
050977 - BILIRUBIN, DIRECT 0.2 mg/dL 0.1 - 0.5 [662]
050978 - CHOLESTEROL 178 mg/dl 100 - 240 [662]
050979 - TRIGLYCERIDE 65 mg/dl 10 - 190 [662]
050980 - HIGH DENSITY LIPOPROT (HDL) 69 mg/dl Ref: >=35 [662]
050981 - Eval: HDL <35 is associated with increased risk of CAD.
050982 - LDL CHOL(Calculated) 96 mg/dl Ref: <=131 [662]
050983 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050984 -
050986 - ..
050987 - 21. Clinical Reminder Activity
050988 - MED REC NON PRIMARY CARE:
050989 - Current medications reviewed with patient/caregiver and reconciliation
050990 - of medications related to today's visit completed, including non-VA
050991 - medications and discrepancies, if identified, were addressed.
050992 - Medication changes and the importance of medication management were
050993 - reviewed with the patient/caregiver today based on individual needs.
050994 - Patient/caregiver acknowledged understanding of instructions as
050995 - stated. An updated list of reconciled medications has been provided
050996 - to the patient/caregiver.
050997 -
050998 - /es/ Paul C. Simpson MD
050999 - Attending MD Cardiology, NPI 1548374093
051000 - Signed: 05/04/2016 12:13
051001 -
051002 -
051003 -
051004 -
051005 -
051006 -
051007 -
051008 -
051009 -