082232 -
082233 -
082235 - ..
082236 - Gina took a picture of us waiting for the "water to boil"...
082237 -
082238 -
082239 - 
082240 -
082241 -
082243 - ..
082244 - Took picture of lipoma tumor to be removed today...
082245 -
082246 -
082247 -
082248 - 
082249 -
082250 -
082252 - ..
082253 - On 183031 1000 Doctor Simpson asked about scratches on the back.
082254 - ref SDS 31 IN85 Today, Kathy took a picture...
082255 -
082256 -
082257 - 
082258 -
082259 -
082260 -
082261 -
082263 - ..
0823 -
0824 -
0825 - 1243
0826 -
082601 - Nancy Arogon visited. She is the anesthesiology nurse.
082603 - ..
082604 - Nancy set the IV catheter for the surgery procedure. Asked her to use
082605 - left arm for the IV, so we can save the right arm for Doctor Lee's GI
082606 - team to set IV's, with another EGD scheduled on 190215. Nancy said
082607 - the left will work well for today.
082609 - ..
082610 - Nancy proposed placing IV catheter on lower right (inner) edge of left
082611 - arm just above the wrist. Discussed using veins closer to the elbow.
082612 - There is always good success with this location, and less pain than
082613 - lower on the arm. Nancy explained work today, will be better with IV
082614 - catheters set lower on the arm near the wrist. She advised that after
082615 - being put to sleep, the patient will be flipped over laying on
082616 - stomach, so the doctor has access to the back. Head will be supported
082617 - in a perimeter frame. Arms will be extended above the head and bent
082618 - at the elbows. Medication flowing in IV's set near bent elbows can
082619 - get clogged. This risk is avoided by setting the IV down near the
082620 - wrist.
082622 - ..
082623 - Nancy planned to use a numbing agent to reduce pain setting the IV
082624 - near the wrist. Agreed to the procedure.
082625 -
082626 - [On 190206 1143 letter to Doctor Stewart commends Nancy's
082627 - work setting IV, and notifying patient of progress toward
082628 - starting surgery. ref SDS 38 XT59
082630 - ..
082631 - Numbing agent scenario worked pretty well. There was pain level 9 for
082632 - an instant penetrating the skin and pushing into the blood vessel near
082633 - the writs. Pain quickly declined, as numbng took effect. Injecting
082634 - the larger needle had pain level 2, very tolerable. There was blood
082635 - flow, so did not need multiple needle sticks today.
082637 - ..
082638 - Case study on sticks required to set IV catheters is reported on
082639 - 110429 1230. ref SDS 16 UO3G
082640 -
082641 -
082642 - 
082643 -
082645 - ..
082646 - Nancy indicated awareness patient suffered stroke symptoms getting 6
082647 - mg versed for EGD procedure several years ago, and so demonstrates
082648 - hypersensitivity to versed. She explained that Doctor Stewart has
082649 - advised anesthesology team not to use conscious sedation today, so
082650 - versed will not be injected. They will use conventional anesthesia.
082651 - This aligns with discussions last Friday meeting with Doctor Choukalas
082652 - on 190201 0800. ref SDS 35 KX3I Letter confirmed understandings to
082653 - Doctor Choukalas with copy to Doctor Stewart yesterday on 190203 1528.
082654 - ref SDS 37 TL3G
082656 - ..
082657 - Advised Nancy that the throat has a lot of bubbles today. Have gone
082658 - to the restroom several times to spit up salavia buildup above LESV.
082659 - During surgery today, need to be slightly tilted with head higher than
082660 - feet to prevent backflow from stomach into esophagus, as done during
082661 - CABG surgery on 091022 0700. ref SDS 5 0U4O
082663 - ..
082664 - Nancy said a tube for anesthesia will be pushed into the throat.
082665 - This will prevent backflow into esophagus.
082667 - ..
082668 - Nancy said surgery has a long project ahead of us. Expects it will be
082669 - after 1500 or later, before this surgery, and so we will not get out
082670 - of the hospital on the way home until after 1800.
082671 -
082672 - [...below on 190204 1200 at 1445 Nancy pushed patient on
082673 - gurney into OR for surgery, about 15 minutes ahead of
082674 - initial schedule. ref SDS 0 B46I
082675 -
082676 -
082678 - ..
0827 -
0828 -
0829 - 1321
0830 -
083001 - Doctor Marilyn Michela visited. She will perform anesthesia during
083002 - the procedure today. The doctor reviewed the medical chart, and was
083003 - very helpful explaining the work process, and answering questions.
083005 - ..
083006 - Doctor Michela was thoroughly familiar with prior stroke symptoms
083007 - following conscious sedation with versed 6 mg. She presented work
083008 - plan to use anesthesia with drugs that will place the patient in sleep
083009 - condition, and will not use versed today.
083010 -
083011 - [On 190206 1143 letter notifies Doctor Stewart she has
083012 - great crew - Doctor Michela was well informed on versed
083013 - issue, and very helpful during preparation. ref SDS 38 VN9S
083014 -
083015 -
083016 -
083017 -
083018 -
083020 - ..
0831 -
0832 -
0833 - 1403
0834 -
083401 - Doctor Yonjae J Kim, a young resident, visited. He marked the site of
083402 - surgery on the back. The doctor reported observing scratch like marks
083403 - on the back...
083404 -
083406 - ..
083407 - 
083408 -
083410 - ..
083411 - [On 190206 1143 letter notifies Doctor Stewart she has
083412 - great crew - Doctor Kim very helpful during preparation.
083413 - ref SDS 38 VN9S
083415 - ..
083416 - Asked about pausing pushups?
083418 - ..
083419 - Doctor Kim said pushups and other strenuous activity should be paused
083420 - until after follow up examination by Doctor Stewart in about 2 weeks.
083422 - ..
083423 - He indicated the prior surgery has completed, so this will begin in
083424 - about 40 minutes.
083425 -
083426 -
083427 -
083429 - ..
0835 -
0836 -
0837 - 1422
0838 -
083801 - Nancy returned.
083802 -
083803 - She brought an antiacid drink in a sealed plastic container. She
083804 - removed the cap. Nancy said the tast is very disagreeable. Drank
083805 - about 3 FL of this stuff. Said the taste is very tolerable.
083807 - ..
083808 - Nancy laughed and said she tells everyone it tastes very bad, so they
083809 - will hopefully be favorably surprised the taste is a little better.
083811 - ..
083812 - Nancy placed heart monitoring probes on the shoulders and sides of the
083813 - back.
083814 -
083815 -
083816 -
083818 - ..
0839 -
0840 -
0841 - 1445
0842 -
084201 - Nancy pushed the gurney into the OR for surgery. This is about 15
084202 - minutes ahead of her initial estimate of 1500, per above. ref SDS 0
084203 - RH4H Congratulated Nancy on good psychology being "ahead of
084204 - schedule." She laughed!
084206 - ..
084207 - Was awake for about 5 minutes inside the OR. Looked familiar from
084208 - prior visits.
084210 - ..
084211 - Did not see Doctor Stewart.
084213 - ..
084214 - After being put to sleep, the team flipped me over to lay face down,
084215 - as Nancy explained earlier, per above. ref SDS 0 UL6H
084216 -
084217 -
084218 - [On 190206 1143 letter thanks Doctor Stewart for surgery,
084219 - commends support crew, including Doctor Choukalas
084220 - coordinating anesthesia issues, ref SDS 39 XT59; advises no
084221 - pain Monday after surgery, swelled upper lip and minor
084222 - stomach and rib pain on 190205, and 190206, unexpected for
084223 - surgery on back, took pain pill on 190205. ref SDS 38 XT62
084224 - Asks about checking surgery wound post-surgery. ref SDS 38
084225 - XT6U
084226 -
084227 -
084229 - ..
0843 -
0844 -
0845 - 1610
0846 -
084601 - Doctor Stewart called Kathy.
084602 -
084603 - Said lipoma tumor was encapsulated, which is a good signal that it
084604 - was benign.
084606 - ..
084607 - The doctor cautioned against heavy exertion. Kathy asked about
084608 - pushups. She understood Doctor Stewart to say pause pushups and other
084609 - heavy lifting until after she makes an examination in 2 weeks.
084611 - ..
084612 - The doctor gave no restrictions on hiking.
084613 -
084614 -
084615 -
084617 - ..
0847 -
0848 -
0849 - 1720
0850 -
085001 - Woke up or Mike woke me up in Recovery. Kathy was there. The team
085002 - had removed clothing from the locker where Gina stored them earlier
085003 - today, per above, ref SDS 0 315M, and brought them to Recovery.
085005 - ..
085006 - Picture shows lipoma tumore removed...
085007 -
085008 -
085009 - 
085010 -
085012 - ..
085013 - Dressed and received discharge instructions...
085014 -
085015 - 1. Take medications normally prescribed.
085016 -
085017 - 2. Discharge activity: no restrictions
085018 -
085019 - This was modified by Doctor Stewart in her call to Kathy at
085020 - 1610, per above. ref SDS 0 UY6O
085022 - ..
085023 - 3. Surgery incison covered with surgical glue. Don't shower for
085024 - 24 hours.
085026 - ..
085027 - After shower don't rub surgery site with towel, pad the area.
085029 - ..
085030 - 4. Meet with Doctor Stewart within 2 weeks. Telephone number for
085031 - General Surgery...
085032 -
085033 - 415 379 5672
085034 -
085035 - [On 190211 1138 Roxy called and scheduled meeting on 190226
085036 - 1530, with Doctor Stewart to review progress recovering
085037 - from surgery on 190104. ref SDS 40 VN9S
085039 - ..
085040 - [On 190212 0908 received letter from Doctor Stewart saying
085041 - to call or visit her in the Surgery Clinic. ref SDS 41 VN9S
085043 - ..
085044 - 5. If symptoms worsen call...
085045 -
085046 - 800 733 0502
085047 -
085048 -
085049 -
085050 -
085052 - ..
0851 -
0852 -
0853 - 1735
0854 -
085401 - Departed VA for home. Raining steadily entire trip.
085402 -
085403 -
085405 - ..
0855 -
0856 -
0857 - 1924
0858 -
085801 - Arrived home.
085802 -
085803 -
085804 -
085805 -
0859 -
SUBJECTS
Default Null Subject Account for Blank Record
0903 -
090401 - ..
090402 - Release of Information ROI CD Contents Received on 190316
090403 -
090404 - Request records on CD from ROI for this medical encounter due to
090405 - continual difficulties downloading medical records from VA website
090406 - at...
090407 -
090408 - https://www.myhealth.va.gov/mhv-portal-web/track-health
090409 -
090416 - ..
090417 - Stored Progess Notes for procedure on 180627 at location...
090418 -
090419 - F:\05\00003\SM\CC\AGMJ\20190204-120000\mhv_WELCH_20190224_1309.txt
090420 -
090421 -
090422 -
090423 - 1. Date/Time: 04 Feb 2019 @ 1652
090424 - Note Title: ANESTHESIA ATTENDING PACU DC NOTE
090425 - Location: San Francisco CA VAMC
090426 - Signed By: YEE,CURTIS W
090427 - Co-signed By: YEE,CURTIS W
090428 - Date/Time Signed: 04 Feb 2019 @ 1653
090429 - -------------------------------------------------------------------------
090431 - ..
090432 - LOCAL TITLE: ANESTHESIA ATTENDING PACU DC NOTE
090433 - STANDARD TITLE: ANESTHESIOLOGY ATTENDING NOTE
090434 - DATE OF NOTE: FEB 04, 2019@16:52 ENTRY DATE: FEB 04, 2019@16:53:15
090435 - AUTHOR: YEE,CURTIS W EXP COSIGNER:
090436 - URGENCY: STATUS: COMPLETED
090438 - ..
090439 - ANESTHESIA ATTENDING PACU DC Note
090441 - ..
090442 - Patient examined: Awake, Alert, Oriented, Vital Signs Stable, Denies
090443 - Nausea at Present
090445 - ..
090446 - Anesthesia Technique in OR: GA
090448 - ..
090449 - D/C O2 Sat: 96% on Room Air
090451 - ..
090452 - No Apparent Anesthetic Complications
090453 - Visual Analogue Scale Pain: 0/10.
090455 - ..
090456 - PACU Pain Management:none
090457 -
090459 - ..
090460 - Planned Post Op Pain Management PO
090461 -
090462 - Ready for discharge to ASU. Patient is medically stable, able to
090463 - provide self-care, and can stay in an unsupervised setting.
090464 -
090465 - /es/ CURTIS W YEE
090466 - CRNA
090467 - Signed: 02/04/2019 16:53
090468 - -------------------------------------------------------------------------
090469 -
090470 - =========================================================================
090471 - 2. Date/Time: 04 Feb 2019 @ 1618
090472 - Note Title: PICIS ANESTHESIA NOTE
090473 - Location: San Francisco CA VAMC
090474 - Signed By: AUTH-PICIS,CARESUITE
090475 - Co-signed By: AUTH-PICIS,CARESUITE
090476 - Date/Time Signed: 04 Feb 2019 @ 1619
090477 - -------------------------------------------------------------------------
090479 - ..
090480 - LOCAL TITLE: PICIS ANESTHESIA NOTE
090481 - STANDARD TITLE: ANESTHESIOLOGY NOTE
090482 - DATE OF NOTE: FEB 04, 2019@16:18 ENTRY DATE: FEB 04, 2019@16:19:55
090483 - AUTHOR: AUTH-PICIS,CARESUIT EXP COSIGNER:
090484 - URGENCY: STATUS: COMPLETED
090486 - ..
090487 - See linked PDF file
090488 -
090489 - /es/ CARESUITE AUTH-PICIS
090490 - Picis Automated Image Capture
090491 - Signed: 02/04/2019 16:19
090492 - -------------------------------------------------------------------------
090493 -
090494 - =========================================================================
090495 - Date/Time: 04 Feb 2019 @ 1618
090496 - Note Title: DISCHARGE INSTRUCTIONS NOTE
090497 - Location: San Francisco CA VAMC
090498 - Signed By: KIM,YONJAE J
090499 - Co-signed By: KIM,YONJAE J
090500 - Date/Time Signed: 04 Feb 2019 @ 1624
090501 - -------------------------------------------------------------------------
090503 - ..
090504 - LOCAL TITLE: DISCHARGE INSTRUCTIONS NOTE
090505 - STANDARD TITLE: PHYSICIAN DISCHARGE NOTE
090506 - DATE OF NOTE: FEB 04, 2019@16:18 ENTRY DATE: FEB 04, 2019@16:19:11
090507 - AUTHOR: KIM,YONJAE J EXP COSIGNER: STEWART,LYGIA
090508 - URGENCY: STATUS: COMPLETED
090510 - ..
090511 - DISCHARGE MEDICATIONS
090512 - Patient is being discharged to home.
090513 - IV Access for Discharge
090514 - Patient should be discharged with NO IV access. All IV's should be
090515 - removed prior to discharge.
090516 -
090517 - Detailed List of Medications and Instructions
090519 - ..
090520 - To the Patient: The following is a list of ALL medications you should
090521 - take once you leave the hospital. Those listed as "pending" may have
090522 - slightly different instructions when you receive them. Always follow the
090523 - instructions on the prescription bottle. Ask your doctor, nurse, or
090524 - pharmacist if you have any questions about your medications.
090525 -
090526 - Summary of medication modifications:
090527 - NEW medications:
090528 - - Acetaminophen 975 mg every 6 hours. Do not exceed 4000 mg of acetaminophen
090529 - within 24 hours. Take as long as you have pain at surgical site
090530 - - Ibuprofen 400 mg three times a day with meals as needed for pain that is not
090531 - controlled by acetaminophen
090532 - - Oxycodone 5 mg four times a day as needed for pain not controlled by
090533 - acetaminophen or ibuprofen
090535 - ..
090536 - Prior medications with CHANGES IN THE DOSE:
090537 - None
090539 - ..
090540 - Prior medications to be TO BE CONTINUED AS THEY WERE:
090541 - Take all medications as prescribed
090543 - ..
090544 - Prior medications that SHOULD BE STOPPED:
090545 - None
090546 -
090548 - ..
090549 - Active Outpatient Medications (including Supplies):
090550 -
090551 - Outpatient Medications Status
090552 - ========================================================================
090553 - =
090554 - 1) ACETAMINOPHEN 325MG TAB TAKE THREE TABLETS ORALLY PENDING
090555 - EVERY 6 HOURS FOR PAIN.
090556 - 2) AMMONIUM LACTATE 12% LOTION APPLY LOTION TOPICALLY ACTIVE
090557 - EVERY DAY AS DIRECTED TO FEET AFTER BATHING FOR DRY
090558 - SKIN
090559 - 3) ATORVASTATIN CALCIUM 20MG TAB TAKE ONE-HALF TABLET ACTIVE
090560 - ORALLY EVERY OTHER DAY FOR CHOLESTEROL **NOTE
090561 - DIRECTIONS**
090562 - 4) CALCIUM CARB 500MG (CA 200MG) CHEW TAB CHEW TWO ACTIVE
090563 - TABLETS ORALLY AT BEDTIME
090564 - 5) EZETIMIBE 10MG TAB TAKE ONE TABLET ORALLY EVERY OTHER ACTIVE
090565 - DAY
090566 - 6) HYDROCODONE 5MG/ACETAMINOPHEN 325MG TAB TAKE 1 TABLET ACTIVE
090567 - ORALLY EVERY DAY AS NEEDED FOR PAIN. MAY TAKE 1
090568 - ADDITIONAL TABLET EACH TIME IF PAIN IS NOT
090569 - CONTROLLED.
090570 - 7) IBUPROFEN 400MG TAB TAKE ONE TABLET ORALLY THREE PENDING
090571 - TIMES A DAY WITH MEALS AS NEEDED FOR PAIN OR
090572 - INFLAMMATION.
090573 - 8) OXYCODONE HCL 5MG TAB ***PLAIN*** TAKE ONE TABLET PENDING
090574 - ORALLY FOUR TIMES A DAY AS NEEDED FOR PAIN.
090575 - 9) PEG 400 0.4%/PROP GLYCOL 0.3% OPH SOLN INSTILL 1 DROP ACTIVE
090576 - IN BOTH EYES FOUR TIMES A DAY FOR DRY EYES
090577 -
090579 - ..
090580 - Active Medications from Remote Data
090582 - ..
090583 - FAMOTIDINE 40MG TAB
090584 - Sig: TAKE TWO TABLETS BY MOUTH TWICE A DAY FOR SEVERE ACID REFLUX
090585 - AND ESOPHAGUS NARROWING.
090586 - Quantity: 360 Days Supply: 90
090587 - 3 refills remaining until 07/12/19
090588 - Last filled 12/01/18 at NORTHERN CALIFORNIA HCS (Active)
090590 - ..
090591 - AL OH 400MG/MG OH 400MG/SIMETHICONE 40MG/5ML LIQUID(360ML)
090592 - Sig: TAKE 2 TABLESPOONFULS BY MOUTH FOUR TIMES A DAY AS NEEDED
090593 - FOR ACID REFLUX SYMPTOMS
090594 - Quantity: 4 Days Supply: 30
090595 - 11 refills remaining until 12/19/19
090596 - Last filled 12/19/18 at NORTHERN CALIFORNIA HCS (Active)
090598 - ..
090599 - CALCIUM CARBONATE 500MG TAB,CHEWABLE
090600 - Sig: CHEW TWO TABLETS BY MOUTH ONCE DAILY FOR ACID REFLUX
090601 - Quantity: 150 Days Supply: 75
090602 - 3 refills remaining until 07/12/19
090603 - Last filled 10/08/18 at NORTHERN CALIFORNIA HCS (Active)
090605 - ..
090606 - PANTOPRAZOLE NA 40MG TAB,EC
090607 - Sig: TAKE ONE TABLET BY MOUTH EVERY EVENING ABOUT 30 MINUTES
090608 - BEFORE DINNER. (ADD TO HIGH DOSE FAMOTIDINE)
090609 - Quantity: 90 Days Supply: 90
090610 - 3 refills remaining until 07/12/19
090611 - Last filled 12/25/18 at NORTHERN CALIFORNIA HCS (Active)
090612 -
090613 -
090615 - ..
090616 - INPATIENT ATTENDING
090617 - Attending Physician for this inpatient stay is: Dr. Lygia Stewart
090618 -
090620 - ..
090621 - DISCHARGE DATE/TIME
090622 - Anticipated Discharge Date/Time: Feb 4,2019
090623 - Comments:
090624 -
090626 - ..
090627 - DISCHARGE DIAGNOSES
090628 - Primary Diagnosis: Upper back Lipoma
090629 - Secondary Diagnosis:
090630 -
090632 - ..
090633 - DISCHARGE CONDITION
090634 - GOOD
090635 -
090637 - ..
090638 - DISCHARGE DISPOSITION
090639 - Home
090640 -
090642 - ..
090643 - DISCHARGE ACTIVITY
090644 - Activities: No restrictions
090645 -
090647 - ..
090648 - DISCHARGE TRANSPORTATION
090649 - Transportation: Self, family, or other non-VA transportation
090650 -
090652 - ..
090653 - DISCHARGE DIET
090654 - NOT CURRENTLY AN INPATIENT
090655 - No restrictions
090656 -
090657 - Your last calculated Body Mass Index (BMI) is: 31.8 (Obesity Level I)
090658 - Patients with a BMI less than 18.5 should contact our nutrition clinic
090659 - at (415) 221-4810 x2895 for nutrition services. Patients with a BMI over
090660 - 30 should speak with their primary care provider about weight loss.
090661 -
090663 - ..
090664 - DISCHARGE SMOKING INSTRUCTIONS
090665 - Don't smoke. If you need help quitting smoking, talk to your Primary
090666 - Care Provider or call the Smoking Cessation Hotline at (415) 379-5566
090667 - or the Smoking Cessation Clinic (415) 750-2050.
090668 -
090670 - ..
090671 - DISCHARGE WOUND INSTRUCTIONS
090672 - WOUND CARE INSTRUCTIONS
090673 -
090674 - Your incision is covered with surgical glue. You may shower starting
090675 - tomorrow 2/5/2019. Allow the soap and water to run over the incision
090676 - and gently pat dry. Do not rub, and do not submerge underwater for 2
090677 - weeks.
090678 -
090680 - ..
090681 - SPECIAL DISCHARGE INSTRUCTIONS
090682 - None
090683 -
090685 - ..
090686 - DISCHARGE FOLLOW-UP APPOINTMENTS
090687 - A follow up appointment is important after your discharge home. Refer
090688 - to the attached list for your future appointments.
090689 -
090690 - If you do not have a future appointment scheduled after discharge and
090691 - you are not contacted within 4 days with an appointment, please call the
090692 - following clinic(s) and ask to schedule your post discharge follow up
090693 - appointment(s).
090695 - ..
090696 - Please follow up with the general surgery clinic in 2 weeks
090697 - Clinic 1: General Surgery: Call 415-379-5672
090698 -
090700 - ..
090701 - DISCHARGE CALL INFORMATION
090702 - For more information or if your symptoms worsen call Telephone Care at
090703 - 1-800-733-0502.
090704 -
090705 - Other numbers to call:
090706 -
090707 - If your prescription has refills: please call (415) 750-2233 or
090708 - 1-800-847-3203 to reach our automated refill line. The prescription
090709 - number and number of refills remaining will be on your prescription
090710 - label.
090712 - ..
090713 - Link to your health care by signing up for MyhealtheVet at
090714 - www.myhealth.va.gov to manage your VA Prescription refills, personal
090715 - health journals and more! Contact the My HealtheVet POC at 415-221-4810
090716 - ext 3834 for more info.
090718 - ..
090719 - If there are no refills for the medication: please contact your provider
090720 - if you need new prescriptions.
090722 - ..
090723 - If you wish to have a copy of your discharge summary sent to a provider
090724 - not at the San Francisco VA Medical Center, please contact Release of
090725 - Information at (415) 750-6607 or stop by room 176, in building 2 of the
090726 - Medical Center.
090728 - ..
090729 - A copy of these instructions was given to the patient at discharge.
090730 -
090731 -
090732 - /es/ YONJAE J KIM
090733 - Surgery Resident NPI#1700317146
090734 - Signed: 02/04/2019 16:24
090735 -
090736 - /es/ Lygia Stewart, M.D., 2860
090737 - Chief General Surgery
090738 - Cosigned: 02/05/2019 08:48
090739 - -------------------------------------------------------------------------
090740 -
090741 - =========================================================================
090742 - Date/Time: 04 Feb 2019 @ 1616
090743 - Note Title: BRIEF OPERATIVE NOTE (SURG)
090744 - Location: San Francisco CA VAMC
090745 - Signed By: KIM,YONJAE J
090746 - Co-signed By: KIM,YONJAE J
090747 - Date/Time Signed: 04 Feb 2019 @ 1618
090748 - -------------------------------------------------------------------------
090750 - ..
090751 - LOCAL TITLE: BRIEF OPERATIVE NOTE (SURG)
090752 - STANDARD TITLE: SURGERY OPERATIVE NOTE
090753 - DATE OF NOTE: FEB 04, 2019@16:16 ENTRY DATE: FEB 04, 2019@16:17:04
090754 - AUTHOR: KIM,YONJAE J EXP COSIGNER:
090755 - URGENCY: STATUS: COMPLETED
090757 - ..
090758 - Preop dx: Upper back lipoma
090760 - ..
090761 - Postop dx: Upper back lipoma
090763 - ..
090764 - Procedure: Upper back lipoma excision
090766 - ..
090767 - Type of Anesthesia: General endotracheal
090769 - ..
090770 - Surgeon: Yonjae Kim
090772 - ..
090773 - Attending: Lygia Stewart
090775 - ..
090776 - EBL: 2mL
090778 - ..
090779 - Findings: 4cm x 3cm x 2 cm well encapsulated lipoma within subcutaneous space in
090780 -
090781 - upper back without significant surrounding adhesions.
090783 - ..
090784 - Specimen: Lipoma
090786 - ..
090787 - Complications: None
090788 -
090789 - Pt. disposition: PACU
090790 -
090791 -
090792 - /es/ YONJAE J KIM
090793 - Surgery Resident NPI#1700317146
090794 - Signed: 02/04/2019 16:18
090795 - -------------------------------------------------------------------------
090796 -
090797 - =========================================================================
090798 - Date/Time: 04 Feb 2019 @ 1557
090799 - Note Title: SURGERY ATTENDING OPERATIVE NOTE
090800 - Location: San Francisco CA VAMC
090801 - Signed By: STEWART,LYGIA
090802 - Co-signed By: STEWART,LYGIA
090803 - Date/Time Signed: 04 Feb 2019 @ 1559
090804 - -------------------------------------------------------------------------
090806 - ..
090807 - LOCAL TITLE: SURGERY ATTENDING OPERATIVE NOTE
090808 - STANDARD TITLE: SURGERY ATTENDING OPERATIVE NOTE
090809 - DATE OF NOTE: FEB 04, 2019@15:57 ENTRY DATE: FEB 04, 2019@15:58:03
090810 - AUTHOR: STEWART,LYGIA EXP COSIGNER:
090811 - URGENCY: STATUS: COMPLETED
090812 -
090813 - Findings at surgery; 4 cm fatty tumor, well-encapsulated, findings c/w
090814 - a lipoma. Successful resection of soft tissue tumor of the back. The patient
090815 - tolerated the procedure well. The plan is for him to go home today.
090816 -
090817 - /es/ Lygia Stewart, M.D., 2860
090818 - Chief General Surgery
090819 - Signed: 02/04/2019 15:59
090820 - -------------------------------------------------------------------------
090821 -
090822 - =========================================================================
090823 - Date/Time: 04 Feb 2019 @ 1436
090824 - Note Title: GENERAL SURGERY H&P NOTE (SURGERY)
090825 - Location: San Francisco CA VAMC
090826 - Signed By: KIM,YONJAE J
090827 - Co-signed By: KIM,YONJAE J
090828 - Date/Time Signed: 04 Feb 2019 @ 1441
090829 - -------------------------------------------------------------------------
090831 - ..
090832 - LOCAL TITLE: GENERAL SURGERY H&P NOTE (SURGERY)
090833 - STANDARD TITLE: SURGERY H & P NOTE
090834 - DATE OF NOTE: FEB 04, 2019@14:36 ENTRY DATE: FEB 04, 2019@14:36:24
090835 - AUTHOR: KIM,YONJAE J EXP COSIGNER:
090836 - URGENCY: STATUS: COMPLETED
090838 - ..
090839 - GENERAL SURGERY NOTE
090841 - ..
090842 - HPI:
090843 - Mr Welch presents for elective excision of his upper back soft tissue mass
090844 - likely to be lipoma. He reports no significant changes to his past medical
090845 - history and has been NPO. He denies active symptoms including chest pain/SOB.
090846 - He is ready to proceed with surgery.
090848 - ..
090849 - From Clinic note on 1/22/2019:
090850 - Mr Welch is a 73 year old man s/p lap Heller myotomy with Dor fundoplication in
090851 - 2009, complicated by dysphagia requiring serial endoscopic dilations. Now is on
090852 - a maintenance schedule of every 4-6 weeks with Dr. Lee of Sacramento VA. Patient
090853 -
090854 - states he routinely gets versed during the EGDs and is concerned about
090855 - cumulative side effects of the medication, but otherwise tolerating the
090856 - procedures well.Able to tolerate a soft mechanical diet. States that his weight
090857 - is stable and he feels well overall with the current plan and lifestyle.
090859 - ..
090860 - He is presenting today with concern for a mass on his upper back. States it's
090861 - been present for many years but recently his partner noticed that it had gotten
090862 - bigger. It causes some discomfort occasionally when he is lying on his back, but
090863 -
090864 - otherwise has no other symptoms. Denies drainage. Denies fevers or chills.
090865 -
090866 - =========================================================================
090867 - PAST MEDICAL HISTORY:
090868 - Computerized Problem List is the source for the following:
090869 -
090870 - 1. Benign unconjugated bilirubinaemia syndrome 10/31/2018
090871 - 2. Metatarsalgia 05/25/2016
090872 - 3. Fall on same level, Onset 00/00/2015 05/25/2016
090873 - 4. History of coronary artery bypass grafting, 10/14/2015
090874 - Onset 10/00/2009
090875 - 5. Hyperlipidemia 10/14/2015
090876 - 6. Body mass index 30+ - obesity 10/14/2015
090877 - 7. Chronic ischemic heart disease 10/14/2015
090878 - 8. Esophageal stricture (SNOMED CT 63305008) 05/04/2016
090880 - ..
090881 - PSH:
090882 - Date of Surgery: 02/04/2019
090883 - Surgeon: MOHAMEDALY,SARAH
090884 - Operative Proc(s):
090885 - UPPER BACK MASS EXCISION - EXC BACK LES SC < 3 CM
090887 - ..
090888 - Date of Surgery: 12/16/2009
090889 - Surgeon: CHANG,JEN
090890 - Operative Proc(s):
090891 - LAPAROSCOPIC HELLER MYOTOMY, DOR FUNDOPLICATION - LAP MYOTOMY HELLER
090893 - ..
090894 - Date of Surgery: 10/22/2009
090895 - Surgeon: CAMBRONERO,NEIL
090896 - Operative Proc(s):
090897 - CABG - CABG ARTERY-VEIN TWO
090898 -
090899 -
090900 - =========================================================================
090901 - ALLERGIES:
090902 - SIMVASTATIN, ROSUVASTATIN
090903 -
090904 - =========================================================================
090905 - MEDICATIONS:
090907 - ..
090908 - Med List for Patient
090909 - --------------------------------------------------------------------------------
090910 - Alphabetized list of outpatient Rx's, inpatient orders, remote and Non-VA meds
090911 - Legend: OPT = VA issued outpatient prescription, INP = VA issued inpatient order
090912 - Non-VA Meds Last Documented On: ** Data not found **
090913 - --------------------------------------------------------------------------------
090914 - Remote AL OH 400MG/MG OH 400MG/SIMETHICONE 40MG/5ML LIQUID(360ML)
090915 - TAKE 2 TABLESPOONFULS BY MOUTH FOUR TIMES A DAY AS NEEDED FOR
090916 - ACID REFLUX SYMPTOMS
090917 - Last Filled: 12/19/18 (Active at NORTHERN CALIFORNIA HCS)
090918 - Days Supply: 30
090919 - Rx Expiration Date: 12/19/19 Refills Remaining: 11
090921 - ..
090922 - OPT AMMONIUM LACTATE 12% LOTION (Status = ACTIVE)
090923 - APPLY LOTION TOPICALLY EVERY DAY AS DIRECTED TO FEET AFTER BATHING FOR
090924 - DRY SKIN
090925 - Last Released: 1/2/19 Days Supply: 30
090926 - Rx Expiration Date: 5/30/19 Refills Remaining: 1
090928 - ..
090929 - OPT ATORVASTATIN CALCIUM 20MG TAB (Status = ACTIVE)
090930 - TAKE ONE-HALF TABLET ORALLY EVERY OTHER DAY FOR CHOLESTEROL **NOTE
090931 - DIRECTIONS**
090932 - Last Released: 1/15/19 Days Supply: 90
090933 - Rx Expiration Date: 9/28/19 Refills Remaining: 2
090935 - ..
090936 - OPT CALCIUM CARB 500MG (CA 200MG) CHEW TAB (Status = ACTIVE)
090937 - CHEW TWO TABLETS ORALLY AT BEDTIME
090938 - Last Released: 11/1/18 Days Supply: 75
090939 - Rx Expiration Date: 11/1/19 Refills Remaining: 3
090941 - ..
090942 - Remote CALCIUM CARBONATE 500MG TAB,CHEWABLE
090943 - CHEW TWO TABLETS BY MOUTH ONCE DAILY FOR ACID REFLUX
090944 - Last Filled: 10/08/18 (Active at NORTHERN CALIFORNIA HCS)
090945 - Days Supply: 75
090946 - Rx Expiration Date: 07/12/19 Refills Remaining: 3
090948 - ..
090949 - OPT EZETIMIBE 10MG TAB (Status = ACTIVE)
090950 - TAKE ONE TABLET ORALLY EVERY OTHER DAY
090951 - Last Released: 12/26/18 Days Supply: 90
090952 - Rx Expiration Date: 11/1/19 Refills Remaining: 3
090954 - ..
090955 - Remote FAMOTIDINE 40MG TAB
090956 - TAKE TWO TABLETS BY MOUTH TWICE A DAY FOR SEVERE ACID REFLUX AND
090957 - ESOPHAGUS NARROWING.
090958 - Last Filled: 12/01/18 (Active at NORTHERN CALIFORNIA HCS)
090959 - Days Supply: 90
090960 - Rx Expiration Date: 07/12/19 Refills Remaining: 3
090962 - ..
090963 - OPT HYDROCODONE 5MG/ACETAMINOPHEN 325MG TAB (Status = ACTIVE)
090964 - TAKE 1 TABLET ORALLY EVERY DAY AS NEEDED FOR PAIN. MAY TAKE 1
090965 - ADDITIONAL TABLET EACH TIME IF PAIN IS NOT CONTROLLED.
090966 - Last Released: 1/10/19 Days Supply: 28
090967 - Rx Expiration Date: 2/9/19 Refills Remaining: 0
090969 - ..
090970 - Remote PANTOPRAZOLE NA 40MG TAB,EC
090971 - TAKE ONE TABLET BY MOUTH EVERY EVENING ABOUT 30 MINUTES BEFORE
090972 - DINNER. (ADD TO HIGH DOSE FAMOTIDINE)
090973 - Last Filled: 12/25/18 (Active at NORTHERN CALIFORNIA HCS)
090974 - Days Supply: 90
090975 - Rx Expiration Date: 07/12/19 Refills Remaining: 3
090977 - ..
090978 - OPT PEG 400 0.4%/PROP GLYCOL 0.3% OPH SOLN (Status = ACTIVE)
090979 - INSTILL 1 DROP IN BOTH EYES FOUR TIMES A DAY FOR DRY EYES
090980 - Last Released: 1/15/19 Days Supply: 30
090981 - Rx Expiration Date: 1/12/20 Refills Remaining: 11
090982 -
090983 - --------------------------------------------------------------------------------
090984 - Other medications previously dispensed in the last year:
090986 - ..
090987 - OPT NAPROXEN 250MG TAB (EXPIRED/90 Days Supply Last Released: 8/6/18)
090988 - TAKE ONE TABLET ORALLY EVERY DAY AS NEEDED FOR PAIN
090989 -
090990 - =========================================================================
090991 - SOCIAL HISTORY:
090992 -
090993 - See HPI
090994 -
090995 - =========================================================================
090996 - FAMILY HISTORY:
090997 -
090998 - No pertinent updates
090999 -
091000 - =========================================================================
091001 - ROS:
091002 - Gen: no f/c/ns, no weight loss
091003 - HEENT: no vision changes, hearing problems, dizziness, swallowing difficulty
091004 - CV: no chest pain, palpitations, PND, or orthopnea
091005 - Lungs: no SOB, no DOE, no cough
091006 - GI: no abdominal pain, nausea/vomiting, diarrhea/constipation,
091007 - melena/hematochezia
091008 - GU: no dysuria, no urinary frequency
091009 - MSK: no joint pain
091010 - Neuro: no neuropathy, no weakness, no HA
091011 -
091012 - =========================================================================
091013 - PHYSICAL EXAM:
091014 - SVS - Vital Signs Selected
091015 - Measurement DT BP PULSE RESP POx
091016 - (L/MIN)(%)
091017 -
091018 - 02/04/2019 12:13 164/81 77 18 98
091020 - ..
091021 - Gen: NAD.
091022 - CV: RRR. No JVD.
091023 - Lungs: Non-labored breathing.
091024 - Abd: NT/ND
091025 - Ext: Warm, well perfused.
091026 - Skin: No rashes or plaques. ~5 cm upper back soft tissue mass.
091027 - Neuro: Alert. Oriented x3. Normal speech. Responds to questions appropria
091028 - tely.
091029 -
091030 - =========================================================================
091031 - ASSESSMENT & PLAN:
091032 - Mr Welch is a 73 year old man s/p lap Heller myotomy with Dor fundoplication in
091033 - 2009, complicated by dysphagia requiring serial endoscopic dilations and CAD s/p
091035 - ..
091036 - CABG in 2009 who presents for excision of his upper back soft tissue mass which
091037 - is likely to be a lipoma. No acute issues identified
091038 - - OR for lipoma excision
091039 -
091040 - /es/ YONJAE J KIM
091041 - Surgery Resident NPI#1700317146
091042 - Signed: 02/04/2019 14:41
091043 - -------------------------------------------------------------------------
091044 -
091045 - =========================================================================
091046 - Date/Time: 04 Feb 2019 @ 1412
091047 - Note Title: ANESTHESIA PREOP DAY OF SURGERY NOTE
091048 - Location: San Francisco CA VAMC
091049 - Signed By: MICHELOW,MARILYN D MD
091050 - Co-signed By: MICHELOW,MARILYN D MD
091051 - Date/Time Signed: 04 Feb 2019 @ 1414
091052 - -------------------------------------------------------------------------
091054 - ..
091055 - LOCAL TITLE: ANESTHESIA PREOP DAY OF SURGERY NOTE
091056 - STANDARD TITLE: ANESTHESIOLOGY E & M NOTE
091057 - DATE OF NOTE: FEB 04, 2019@14:12 ENTRY DATE: FEB 04, 2019@14:12:53
091058 - AUTHOR: MICHELOW,MARILYN D EXP COSIGNER:
091059 - URGENCY: STATUS: COMPLETED
091061 - ..
091062 - [X] Patient positively identified (Name, Social Security Number)
091063 - [X] Surgical plan reviewed
091064 - [X] APO note Reviewed
091065 - [X] No significant change in history or physical
091067 - ..
091068 - [X] Labs reviewed, no significant change in labs
091070 - ..
091071 - [X] Review of systems completed
091072 - [X] Denies fever, chills, nausea, vomiting, diarrhea, new
091073 - acute illness
091074 - [X] Denies chest pain, shortness of breath, orthopnea,
091075 - paroxysmal nocturnal dyspnea
091076 - [X] Denies cough, excessive sputum production, wheezing
091077 - [X] Denies reflux or GERD
091079 - ..
091080 - [X] Allergies reviewed
091081 - [X] Medications taken today reviewed
091082 - [X] Not on BB
091084 - ..
091085 - [X] MED REC NON PRIMARY CARE:
091086 - Medication Reconciliation completed, including non-VA medications and
091087 - discrepancies, if identified, were addressed. Medication, medication
091088 - changes and importance of medication management were reviewed with the
091089 - patient/caregiver. An updated list of reconciled medications have
091090 - been provided to the patient/caregiver.
091092 - ..
091093 - [X] I clicked the REMINDER button to activate MED REC NON PRIMARY
091094 - CARE clinical reminder in CPRS and the FINISH button to activate the
091095 - Clinical Reminder Activity.
091097 - ..
091098 - PHYSICAL EXAM
091099 - [X] Airway examined - no significant change
091101 - ..
091102 - [X] Chest examined - no significant change
091104 - ..
091105 - [X] Heart examined - no significant change
091107 - ..
091108 - [X] Questions answered
091109 - [X] Risks, benefits, and plans discussed, patient understands risks,
091110 - benefits, and plans and wishes to proceed.
091111 - [X] Patient is NPO except for medications
091112 - ANESTHETIC PLAN
091113 - [X] GA
091115 - ..
091116 - Plan for RSI given patient's history of achalasia and persistent reflux when
091117 - flat.
091119 - ..
091120 - Clinical Reminder Activity
091121 - MED REC NON PRIMARY CARE:
091122 - MEDICATION RECONCILIATION:
091123 -
091124 - Current medications reviewed with patient/caregiver and reconciliation
091125 - of medications related to today's visit completed, including non-VA
091126 - medications and discrepancies, if identified, were addressed.
091127 - Medication changes and the importance of medication management were
091128 - reviewed with the patient/caregiver today based on individual needs.
091129 - Patient/caregiver acknowledged understanding of instructions as
091130 - stated.
091132 - ..
091133 - An updated list of reconciled medications has been provided to the
091134 - patient/caregiver.
091135 -
091136 - /es/ MARILYN D MICHELOW MD
091137 - Staff Physician Anesthesia/Critical Care Med
091138 - Signed: 02/04/2019 14:14
091139 - -------------------------------------------------------------------------
091140 -
091141 - =========================================================================
091142 - Date/Time: 04 Feb 2019 @ 1213
091143 - Note Title: AMBULATORY SURGERY PRE-PROCEDURE ASSESSMENT NOTE
091144 - Location: San Francisco CA VAMC
091145 - Signed By: BRAGANZA,GINA L
091146 - Co-signed By: BRAGANZA,GINA L
091147 - Date/Time Signed: 04 Feb 2019 @ 1222
091148 - -------------------------------------------------------------------------
091150 - ..
091151 - LOCAL TITLE: AMBULATORY SURGERY PRE-PROCEDURE ASSESSMENT NOTE
091152 - STANDARD TITLE: SURGERY OUTPATIENT E & M NOTE
091153 - DATE OF NOTE: FEB 04, 2019@12:13 ENTRY DATE: FEB 04, 2019@12:13:50
091154 - AUTHOR: BRAGANZA,GINA L EXP COSIGNER:
091155 - URGENCY: STATUS: COMPLETED
091157 - ..
091158 - Vital signs: BP:164/81 (02/04/2019 12:13)
091159 - Pulse: 77 (02/04/2019 12:13)
091160 - Temp: 98 F [36.7 C] (02/04/2019 12:13)
091161 - Resp: 18 (02/04/2019 12:13) Pulse Ox: 2/4/19 12:13:17 O2:98
091162 - 02 Therapy:Room Air MODE:
091163 - BMI: 31.8 (Obesity Level I)
091165 - ..
091166 - Procedure /Operation Scheduled:
091167 - Surgical: upper back mass/lipoma excision
091168 -
091170 - ..
091171 - Locker assignment/Bag number: 2
091172 -
091174 - ..
091175 - Patient classification Type: Come and Go
091176 - Pre-procedure Instructions re-inforced, Procedure prep completed, Travel
091177 - plans/Instructions re-inforced
091179 - ..
091180 - How does patient plan to get home when discharged? Other:auto
091182 - ..
091183 - Patient will be accompanied by: kathy 916-539-2440
091185 - ..
091186 - PAIN ASSESSMENT:
091187 - No, denies pain
091188 - REVIEW OF MEDICATION/ALLERGIES
091189 - ALLERGIES: SIMVASTATIN, ROSUVASTATIN
091190 -
091191 - Has the patient brought any of their medications with them? No
091193 - ..
091194 - ACTIVE OUTPATIENT MEDICATIONS(including supplies):
091195 - Computer is the source for the following medication list:
091197 - ..
091198 - ATORVASTATIN CALCIUM 20MG TAB
091199 - PEG 400 0.4%/PROP GLYCOL 0.3% OPH SOLN
091200 - HYDROCODONE 5MG/ACETAMINOPHEN 325MG TAB
091201 - AMMONIUM LACTATE 12% LOTION
091202 - EZETIMIBE 10MG TAB
091203 - CALCIUM CARB 500MG (CA 200MG) CHEW TAB
091205 - ..
091206 - Reviewed Medication Profiles: Yes Explain:
091207 - Does patient take any NON-VA prescribed medications, over the counter
091208 - medications, vitamins, herbals, or dietary supplements: Yes Specify:
091210 - ..
091211 - REVIEW OF SYSTEMS:
091212 - CARDIOVASCULAR: Coronary Artery Bypass Graft cad, chronic ischemic
091213 - heart ds, hld
091214 - RESPIRATORY: remote smoking in childhood
091215 - METABOLIC/ENDOCRINE: Patient denies problems
091216 - NEUROLOGICAL: Patient denies problems
091217 - GENITOURINARY: Patient denies problems
091218 - GASTROINTESTINAL: esophageal stricture s/p laphellar myotomy w/dor
091219 - fundopkication, dysphagia
091220 - MUSCULOSKELETAL: left knee surgery
091221 - HEENT: HEENT: T and A
091222 - OTHER: Yes, Describe: benign unconjugated bilirubinemai sundrome
091224 - ..
091225 - SKIN
091226 - Patient used CHG scrub brush before surgery? Yes
091227 - Patient used chg cloth at home:
091228 - Chg cloth used in preop asu:
091229 - Mupirocin ointment applied to both nostrils per MD order? NA
091230 -
091231 - Requires 2 RN skin assessment on admission
091233 - ..
091234 - RN second Verifier: reyes,emerita
091235 - BRADEN SKIN RISK ASSESSMENT
091237 - ..
091238 - Sensory Perception:4 = No Impairment
091239 - Moisture: 4 = Rarely Moist
091240 - Activity: 4 = Walks Frequently
091241 - Mobility: 4 = No Limitation
091242 - Nutrition: 4 = Excellent
091243 - Friction: 3 = No Apparent Problem
091244 - 19-23 No Risk
091245 - Score: 23
091247 - ..
091248 - SKIN PATCHES
091249 - The patient does not have any patches on the skin.
091250 -
091252 - ..
091253 - MAJOR RISK FACTORS / SPECIAL POPULATIONS
091254 - The patient does not have any spinal cord injury, paralysis or
091255 - neurologic disease.
091257 - ..
091258 - CURRENT SKIN ASSESSMENT
091259 - Skin Color:
091260 - Color: Normal for ethnic group
091261 - Skin Temperature
091262 - Temp: Warm
091263 - Skin Moisture
091264 - Moisture: Dry
091265 - Skin Turgor
091266 - Turgor: Within normal limits
091268 - ..
091269 - SKIN PROBLEMS
091270 - No wounds, pressure ulcers or other skin problems.
091271 - FALL RISK ASSESSMENT
091272 - Not Applicable, Come & Go or Same Day Surgery/Procedure
091273 - O: ambulatory without difficulty, accompanied by kathy npo since mn with
091274 - famotidine taken, pt needs marking, chart needs H&P, attending note in
091275 -
091277 - ..
091278 - A: Patient is: Oriented to Self, Oriented to Person, Oriented to Place,
091279 - Oriented to Time, Anxious
091281 - ..
091282 - NPO?
091283 - Yes
091284 - Type of fluid and the time last drank: na
091285 - Volume of fluid: na
091287 - ..
091288 - P: Continue ASU guidelines for care
091289 -
091290 - /es/ GINA L BRAGANZA
091291 - VOCATIONAL NURSE
091292 - Signed: 02/04/2019 12:22
091293 - -------------------------------------------------------------------------
091294 -
091295 - =========================================================================
091296 - Date/Time: 04 Feb 2019 @ 0754
091297 - Note Title: SURGERY ATTENDING PRE-OP NOTE
091298 - Location: San Francisco CA VAMC
091299 - Signed By: STEWART,LYGIA
091300 - Co-signed By: STEWART,LYGIA
091301 - Date/Time Signed: 04 Feb 2019 @ 0758
091302 - -------------------------------------------------------------------------
091304 - ..
091305 - LOCAL TITLE: SURGERY ATTENDING PRE-OP NOTE
091306 - STANDARD TITLE: SURGERY ATTENDING PRE OPERATIVE E & M NOTE
091307 - DATE OF NOTE: FEB 04, 2019@07:54 ENTRY DATE: FEB 04, 2019@07:54:07
091308 - AUTHOR: STEWART,LYGIA EXP COSIGNER:
091309 - URGENCY: STATUS: COMPLETED
091311 - ..
091312 - Date and time the patient was seen and evaluated: Jan 22, 2019@15:00
091314 - ..
091315 - Evaluation findings: Mr. Welch is a 73 year old man with a soft tissue mass on
091316 - his back that has been present for many years. He feels it has increased in
091317 - size recently. The mass is 5 cm, soft, non-tender, and located in the middle of
091318 -
091319 - the upper back.
091321 - ..
091322 - Diagnosis(es): Likely back lipoma.
091324 - ..
091325 - Treatment plan and/or procedure to be performed: Resection of the back mass.
091327 - ..
091328 - Discussion with the patient of risks, benefits, potential complications and
091329 - alternatives to planned surgery was done and he wishes to proceed. I concur
091330 - with the resident's initial diagnosis and treatment plan.
091331 -
091332 - /es/ Lygia Stewart, M.D., 2860
091333 - Chief General Surgery
091334 - Signed: 02/04/2019 07:58
091335 - -------------------------------------------------------------------------
091336 -
091337 -
091338 -
091339 - ------------------------- VA PATHOLOGY REPORTS --------------------------
091341 - ..
091342 - Source: VA
091343 - Last Updated: 24 Feb 2019 @ 1309
091345 - ..
091346 - Sorted By: Date Obtained (Descending), Type of Report
091348 - ..
091349 - VA Pathology Reports are available 14 calendar days after they have been
091350 - completed. Some studies done at a non-VA facility may not be available or they
091351 - may not necessarily include an interpretation. If you have any questions about
091352 - your information please visit the FAQs or contact your VA health care team.
091353 -
091354 - =========================================================================
091355 - Type of Report: Surgical Pathology
091356 - Specimen: A) BACK FATTY TUMOR - PERM.
091357 - Date Obtained: 04 Feb 2019
091358 - Performing Location: San Francisco CA VAMC4150 CLEMENT STREET, SAN FRANCISCO 94121
091359 - Date Completed: 08 Feb 2019
091360 - -------------------------------------------------------------------------
091361 - SURGICAL PATHOLOGY REPORT
091362 -
091363 -
091365 - ..
091366 - LOCAL TITLE: LR SURGICAL PATHOLOGY REPORT
091367 - STANDARD TITLE: PATHOLOGY REPORT
091368 - DATE OF NOTE: FEB 08, 2019@16:33:33 ENTRY DATE: FEB 08, 2019@16:33:33
091369 - AUTHOR: AHN,GEORGE G EXP COSIGNER:
091370 - URGENCY: STATUS: COMPLETED
091371 -
091372 - $APHDR
091373 -
091375 - ..
091376 - Reporting Lab:
091377 - SAN FRANCISCO VAMC [CLIA# 05D0988226]
091378 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
091379 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
091380 - MEDICAL RECORD | SURGICAL PATHOLOGY
091381 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
091382 - PATHOLOGY REPORT Accession No. SP 19 534
091383 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
091384 - $TEXT
091385 - Submitted by: OR-6. Date obtained: Feb 04, 2019
091386 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
091387 - Specimen (Received Feb 05, 2019 08:37):
091388 - A) BACK FATTY TUMOR - PERM.
091389 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
091390 - BRIEF CLINICAL HISTORY:
091391 - The patient is a 73 year old man who presents with a persistent mass on
091392 - his upper back that he is concereed is increasing in size. He undergoes
091393 - an excision of the mass.
091394 -
091395 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
091396 - PREOPERATIVE DIAGNOSIS:
091397 - SOFT TISSUE MASS
091398 -
091399 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
091400 - OPERATIVE FINDINGS:
091401 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
091402 - POSTOPERATIVE DIAGNOSIS:
091403 - BACK FATTY TUMOR
091404 -
091406 - ..
091407 - Surgeon/physician: YONJAE J KIM
091408 - Attending Surgeon: Lygia Stewart MD
091409 - =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=
091410 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
091411 - PATHOLOGY REPORT Accession No. SP 19 534
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091413 - Pathology Resident: DANIEL V SULLIVAN
091415 - ..
091416 - GROSS DESCRIPTION:
091417 -
091418 - The specimen is received in formalin, labeled with the patient's name and
091419 - social security number and additionally labeled "back fatty tumor" and
091420 - consists of one unoriented piece of yellow tissue (5.5 x 4 x 1.5 cm). The
091421 - specimen is inked black. On cut section the specimen is fatty yellow with
091422 - no discolorations or hemorrhage. Representative sections are submitted in
091423 - cassettes A1-A4. (DVS)
091425 - ..
091426 - FINAL ANATOMIC DIAGNOSIS:
091428 - ..
091429 - SOFT TISSUE, BACK TUMOR, EXCISION:
091430 - SPINDLE CELL LIPOMA; SEE COMMENT
091432 - ..
091433 - Comment: An immunohistochemical stain for CD34 was performed on block
091434 - A1 and showed positive staining, supporting the diagnosis of a spindle
091435 - cell lipoma.
091436 -
091437 - [On 190226 1530 Isagani was not familiar with
091438 - "spindle cell lipoma", ref SDS 42 SR7O; and Doctor
091439 - Stewart was not familiar with this phrase.
091440 - ref SDS 42 PR6T Isagani called Pathology said they
091441 - explained "spindel cell lipoma" is benign and does
091442 - not present medically significant afflictions.
091443 - ref SDS 42 KQ6H
091444 -
091445 -
091446 - /es/ GEORGE G AHN
091447 - STAFF-PHYSICIAN
091448 - Signed Feb 08, 2019@16:33
091449 -
091451 - ..
091452 - Performing Laboratory:
091453 - Surgical Pathology Report Performed By:
091454 - SAN FRANCISCO VAMC [CLIA# 05D0988226]
091455 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
091456 -
091457 - $FTR
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091459 - (End of report)
091460 - GEORGE G AHN dvs| Date Feb 08, 2019
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091462 - WELCH,RODNEY CHARLES STANDARD FORM 515
091463 - ID:561-72-0144 SEX:M DOB:03/01/1945 AGE: 73 LOC:OR6
091464 - PCP: Lauren Rettberg
091465 -
091466 - /es/ GEORGE G AHN
091467 - STAFF-PHYSICIAN
091468 - Signed: 02/08/2019 16:33
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