THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: January 24, 2020 07:05 AM Friday; Rod Welch

VA Cath Lab IVUS angiography Doctor Tietjens found stenosis 0 10 years after CABG x4.

1...Summary/Objective
....Do-it-yourself cardiac bypass surgery: All you need is walking shoes
2...Progress Notes Cardiac Catheterization Evaluate Plaque 10 Years After CABG x4

ACTION ITEMS.................. Click here to comment!

1...little bit of exercise won't do the trick. You need to push

CONTACTS 

SUBJECTS
IVUS Angiogram Cardiac Catheterization All 4 Bypassa Grafts Patent 1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
3303 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3303 -    ..
3304 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
3305 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
330501 - Follow up ref SDS E2 0000. ref SDS E0 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
330502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330506 -             ..
330507 -            [On 200125 0511 letter to Lana reports good results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
330508 -            angiography finding grafts widely patent 10 years after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
330509 -            CABG achieved with high intensity (obsessive compulsive)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330510 -            hiking, ref SDS E7 QF5J, but which also caused paroxysmal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
330511 -            atrial fibrillation (PAF). ref SDS E7 6B41                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
330513 -             ..
330514 -            [On 200125 1825 received letter from Doctor Titus, saying                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
330515 -            "fantastic news, and "big picture" is grafts remain patent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
330516 -            due to healthy lifestyle, which refers to hiking.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
330517 -            ref SDS E8 9C9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
330518 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330521 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330524 -  ..
3306 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3307 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3308 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
3309 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
330901 - On 191206 1425 letter to VAMCSF Cardiology Doctor Simpson, ref SDS A9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
330902 - NE9N, notify possible afib symptoms. ref SDS A9 N874                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
330904 -  ..
330905 - On 191207 0927 Doctor Simpson to order ECG [...electrocariogram...]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330906 - Zio test for AFib, after he returns to work following several weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330907 - out of the office. ref SDS B0 NE9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
330909 -  ..
330910 - On 191213 0849 call from Tina - scheduled install Zio equipment for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330911 - heart monitoring test; meeting room 2A16 on 191216 1230. ref SDS B1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
330912 - NE9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
330914 -  ..
330915 - On 191216 1220 Exmeralda in Cardiology at VAMCSF installed Zio XT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
330916 - heart monitor on left chest; she added 2 plastic tapes to secure the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
330917 - unit against fall off in shower and perspiration during hiking.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330918 - ref SDS B5 AO7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
330920 -  ..
330921 - On 191214 1138 letter to Doctor Simpson in Cardiology at VAMCSF,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
330922 - ref SDS B3 NE9N, reports 8 weeks ago increased hiking route with steep                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
330923 - hills from 11 to 15 miles per day. ref SDS B3 MX58  About a week ago                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
330924 - increased hiking to 20+ miles per day in order to improve weight                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
330925 - control and to raise lipids toward HDL 80. ref SDS B3 MX61  Weight                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
330926 - increased after pausing hiking due to orthopedic pain left knee and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330927 - both feet, which was solved after receiving oxycodone and gabapentin,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
330928 - and applying elastic bandage to left knee. ref SDS B3 MX64  Today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
330929 - before hiking felt chest swaying indicating afib. ref SDS B3 MY30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
330930 - Research indicates walking can aid recovery from afib; during hike                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
330931 - today, will reduce level of effort back to 15 miles per day, and avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
330932 - steeper hills. ref SDS B3 368M  Ask about medication to treat afib.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
330933 - ref SDS B3 MY38  Offer to walk with Doctor Simpson to assist recovery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
330934 - from hip surgery. ref SDS B3 MY41                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
330936 -  ..
330937 - On 191214 1138 at 1324 letter from Doctor Simpson in Cardiology at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
330938 - VAMCSF says to do hiking that has led to symptoms. ref SDS B4 0K4L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
330940 -  ..
330941 - On 191228 1416 letter to Doctor Simpson notify Zio log reports chest                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
330942 - pain hiking with elastic bandage on left knee. ref SDS B7 NE9N 1st                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
330943 - episode hiking 12 miles through Golden Gate Park on 191220, chest pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
330944 - mild lasted on ly .25 miles.  Occurred again next day hiking 20 miles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
330945 - up Crystal Ranch Road. ref SDS B7 B652  Occurred next day on 191222, so                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
330946 - stopped at mile .75 and removed elastic bandage from left leg, pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330947 - ended for rest of 20 mile hike and on subsequent hikes 20 mile past 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
330948 - days. ref SDS B7 B655   Today on 191228, chest pain occurred hiking up                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
330949 - mild hills without elastic bandage on left leg, so ended hike at 7                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
330950 - miles. ref SDS B7 B658  HR 150 - should be 45 - 55. ref SDS B7 B662                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330951 - Seems like bypass saphenous graft failed under elevated load wearing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
330952 - elastic bandage on left knee. ref SDS B7 B665  Pause hiking until hear                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
330953 - from the doctor. ref SDS B7 B668                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
330955 -  ..
330956 - On 191228 1416 at 1534 letter from Doctor Simpson notifies he will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
330957 - order treadmill stress test. ref SDS B7 RK6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
330959 -  ..
330960 - On 191228 1416 at 1537 letter to Doctor Simpson notifies will submit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
330961 - Zio XT device with afib data on Monday, 191230. ref SDS B7 WO6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
330963 -  ..
330964 - On 191229 1243 received letter from Doctor Simpson notifies need to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330965 - get ECG test at VAMCSF before they can schedule treadmill stress test.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
330966 - ref SDS B9 NE9N  Further says to get care in the ER if chest pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
330967 - recurs at rest. ref SDS B9 NH77                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
330969 -  ..
330970 - On 191229 1243 at 1256 letter to Doctor Simpson asks where and when to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
330971 - get ECG test. ref SDS B9 YH8N   Notifies so far chest pain has not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
330972 - occurred at rest; has only occurred when hiking. ref SDS B9 YA48                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
330973 - Notifies of EGD procedure in GI Clinic at VAMC Sacramento on 200107,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
330974 - and getting MRI studies on feet and knees at VAMCSF on 200109.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
330975 - ref SDS B9 YA51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
330977 -  ..
330978 - On 191229 1243 at 1420 received letter from Doctor Simpson advising                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330979 - ECG is done on 2nd floor building 203, and to arrive about 1000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
330980 - ref SDS B9 LG4J  Recommends notifying GI Clinic to delay EGD until                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
330981 - after resolution of current Cardiology issue. ref SDS B9 6H6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330983 -  ..
330984 - On 191229 1243 at 1538 received letter from Doctor Simpson advising                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330985 - ECG was done in this case at the end of Oct, so do not need a new one;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
330986 - next step is for VA to schedule stress test. ref SDS B9 E17N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
330988 -  ..
330989 - On 191229 1243 at 1619 sent letter to Jessica on notifying Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
330990 - to delay next EGD scheduled on 200107 0730 for a month until 200204                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
330991 - 0730. ref SDS B9 4R7J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
330993 -  ..
330994 - On 191229 1243 at 1700 letter thanks Doctor Simpson for advising ECG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
330995 - not needed. ref SDS B9 M48J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
330997 -  ..
330998 - On 191229 1243 at 1946 letter notifies Doctor Simpson that feet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
330999 - elevated on footrest seem swelled.  Cellphone reports HR 38.  That is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331000 - low for me.  Don't feel dizzy or light headed; seems like afib event,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331001 - with chest swaying back and forth. ref SDS B9 MH6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
331003 -  ..
331004 - On 191229 1243 at 1946 letter notifies Doctor Simpson Zio device was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331005 - mailed to company a day early on 191229. ref SDS B9 UA47                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
331007 -  ..
331008 - On 191230 0930 received call from Tina in Cardiology at VAMCSF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
331009 - scheduled treadmill stress test on 200103, ref SDS C1 NE9N, report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
331010 - first at 0700 to ASU on 3rd floor Building 200 for IV, then go to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
331011 - Neuclear Medicine on ground floor building 203. ref SDS C1 GE5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331013 -  ..
331014 - On 191230 0930 at 0938 received letter from Doctor Simpson in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
331015 - Cardiology explaining symptoms reported last night are okay, since not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
331016 - dizzy, until after stress test. ref SDS C1 GF3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331018 -  ..
331019 - On 191230 0930 at 0949 received letter Tina in Cardiology confirming                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331020 - schedule for stress test on 200103 0700, and submitting instructions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331021 - to prepare for the test. ref SDS C1 Q76I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
331023 -  ..
331024 - On 191230 0930 at 1021 letter to Doctor Simpson in Cardiology at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
331025 - VAMCSF reporting stress test has been scheduled on 200301 0700.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331026 - ref SDS C1 9W6F  Reported mild chest pain at rest for 10 minutes, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
331027 - it resolved while writing the letter. ref SDS C1 JY39                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
331029 -  ..
331030 - On 191230 0930 at 1114 received letter from Lauren, NP and PCP in this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
331031 - case; she concurs patient should go to ER if chest pain persists at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
331032 - rest, and should have a driver. ref SDS C1 2S4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331034 -  ..
331035 - On 191230 0930 at 1117 received call from Aladin who is Lauren's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
331036 - assistent in Medical Practice; he indicated Lauren asked him to call                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331037 - and get background on chest pain issue. ref SDS C1 578G  Explained                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
331038 - background is reported in correspondence with Doctor Simpson in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331039 - Cardiology, and this has been copied to Lauren. ref SDS C1 5W6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331041 -  ..
331042 - On 191230 0930 at 1135 responded to Lauren citing call from her                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331043 - assistent, Aladin, and reporting background on current issue is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331044 - reported in correspondence with Doctor Simpson in Cardiology, who is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331045 - directing the work, and that Lauren has been copied on all                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
331046 - correspondence. ref SDS C1 659K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331048 -  ..
331049 - On 200108 1130 Doctor Simspon ordered cardiac catheterization                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
331050 - (Angiogram) to evaluate for failed saphenous bypass graph. ref SDS C8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
331051 - UV3M He also cordered Echocardiogram (ECHO) to evaluate cardiac                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331052 - remodeling that may be causing atrial fibrillation. ref SDS C8 GG4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
331054 -  ..
331055 - On 200113 0841 call from Gina in Cardiology scheduled echocardiogram                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331056 - on 200214 1300 to evaluate for cardiac remodeling causing AF due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
331057 - high-intensity hiking. ref SDS D1 NE9N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
331059 -  ..
331060 - On 200115 0933 called VA Cardiology, ref SDS D3 Q18G; and talked to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
331061 - Sue, who has taken the position of Karen for scheduling and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
331062 - coordinatoing patient procedures. ref SDS D3 NB9G  Sue scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
331063 - cardiac catheterization (angiography) on 200128 0730; and, pause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
331064 - Apixaban blood thinner 2 days before the procedure. ref SDS D3 4L5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
331066 -  ..
331067 - On 200115 0933 at 1747 submitted letter confirming work plan for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
331068 - cardiac catheterization on 200128. ref SDS D3 5J7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
331070 -  ..
331071 - On 200115 0933 at 1936 submitted another letter correcting date error                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331072 - in the letter at 1747. ref SDS D3 4K5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
331074 -  ..
331075 - On 200116 0948 received letter from Sue in Cardiology at VAMCSF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331076 - instructions for cardiac catheterization scheduled 200118, ref SDS D4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
331077 - G367, pause Apixaban 2 days before 200118, ref SDS D4 G45M; NPO after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
331078 - midnight, and until after Cath, ref SDS D4 6S30; bring list of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331079 - medications, ref SDS D4 6S76; bring charger for cellphone, ref SDS D4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
331080 - 4B9H; do not drive for 24 hours after cardiac catheterization.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
331081 - ref SDS D4 6S98                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331083 -  ..
331084 - On 200124 0705 cardiac catheterization angiogram performed by Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331085 - Tietjens, ref SDS 0 V544; found all 4 bypass grafts completely clear -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
331086 - no plaque buildup of any amount.  Saphenous vein grafts in very good                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331087 - condition 10 years after CABG x4; best result he has ever seen.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
331088 - said to continue doing whatever you are doing to achieve this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
331089 - exceptional result. ref SDS 0 ME8G  Doctor asked about hiking and HDL?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
331090 - Hiking 3 - 8 miles per day 4 - 6 times a week yielded HDL 30 at time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331091 - of CABG x4 on 091022.  About 4 years after surger, increased hiking to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
331092 - 11 - 20 miles per day up to 7 days a week, this raised cholesterol to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331093 - HDL 83, that regressed plaque in blood vessels. ref SDS 0 CN7I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
331094 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331095 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331096 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331097 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331099 -  ..
3311 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3312 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3313 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3314 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
331401 - Cardiac catheterization today, following up prior procedure on 091021                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331402 - 0716. ref SDS 7 025B                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
331404 -  ..
331405 - Procedure ordered by Doctor Simpson during meeting on 200108 1130.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
331406 - ref SDS C8 UV3M  Planning was discussed with Cath Lab team led by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
331407 - Doctor Shunk during meeting in the hospital yesterday, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
331408 - 200122 0423. ref SDS E2 6Y5R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
331410 -  ..
331411 - Starting morning feeling mild chest pain think it is PAF from exertion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
331412 - setting up c23 to enter the record.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
331414 -  ..
331415 - Checked vitals again...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
331416 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331417 -        HR.................... 130                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
331418 -        Sinus curve........... very jagged                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
331419 -        Chest pain............ 1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331421 -  ..
3315 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3316 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3317 - 0726                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3318 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
331801 - Doctor Erron Titus visited to discuss the procedure this morning.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331802 - checked heart rate and listened to lungs.  He agreed the heart is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
331803 - racing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
331805 -  ..
331806 - Reported current PAF episode this morning, per above. ref SDS 0 496F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331808 -  ..
331809 - Erron asked if the nursing team has given medications this morning,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
331810 - and specifically Metoprolol Tartrate, which Doctor Simpson ordered be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
331811 - taken twice a day, to replace Metoprolol Succinate given once a day,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331812 - reported yesterday on 200123 0419. ref SDS E3 784L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
331814 -  ..
331815 - This has not been done, possibly because medicines are given to the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
331816 - patient at 0900, after change in nursing 12-hour shifts,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
331818 -  ..
331819 - Explained chest pain has subsided.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
331821 -  ..
331822 - Erron left to arrange for the patient to have Metoprolol Tartrate as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331823 - soon as possible and before leaving for the Cath Lab procedure this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
331824 - morning.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
331826 -  ..
331827 - A few minutes later Long came with his computer workstation and gave                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
331828 - Metoprolol Tartrate medication, ordered by Erron, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
331829 - ref SDS 0 5R5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
331830 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331831 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
331833 -  ..
3319 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3320 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3321 - 0810                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3322 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332201 - Mike came from Cath Lab.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332202 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332203 - Angelica was there and asked to do vitals in order to fulfill the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332204 - nursing protocol.  Mike said okay.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332206 -  ..
332207 - Vitals seem good this morning, something like BP 113 72 54.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332209 -  ..
332210 - Got in a wheel chair.  Mike pushed me into the Cath Lab, about 30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332211 - yards down the hall.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332213 -  ..
332214 - Rolling through Cath Lab hallway, met Susan, who will be providing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332215 - nursing support for the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332217 -  ..
332218 - Also met Doctor Chow, and was told he will be attending today in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332219 - Cath Lab.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332221 -  ..
332222 - Laid on a gurney in the preparation room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332224 -  ..
332225 - Review managing backflow through LESV from achalasia discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332226 - yesterday with Doctor Shunk on 200122 0423. ref SDS E2 064K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332228 -  ..
332229 - Used the restroom before starting the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332231 -  ..
332232 - Mike placed a pillow under my head to prevent backflow.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332234 -  ..
332235 - Cynthia came by and visited briefly.  She had received the copy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332236 - submitted to her of the letter to Doctor Simpson reviewing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332237 - consideration for participating in a clinical trial to test PCSK9 that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332238 - lowers LDL cholesterol, and requires not doing lipid tests for 18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332239 - months.  She was very encouraging for successful angiography                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332240 - procedure, even though that would mean cannot join either of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332241 - clinical trials she is helping Doctor Shunk run.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332243 -  ..
332244 - Mike removed the blood thinner braclet from the left wrist, where the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332245 - cardiac catheter will access a vein for the procedure today.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332246 - placed it on the right wrist.  He shaved the left wrist to prepare for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332247 - the procedure, and also shaved right groin for a backup entry in case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332248 - the left wrist entry fails.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332250 -  ..
332251 - Mike indicated cardiac catheterization entry from the wrist instead of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332252 - the groin has been done the past 2 or 3 years.  The doctor who                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332253 - developed this new procedure came from Norway and taught the Cath Lab                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332254 - team this new procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332256 -  ..
332257 - Mike entered the record in a computer next to the gurney, to log this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332258 - procedure.  Verified name, social security and birth date.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332260 -  ..
332261 - Was wheeled into the Cath Lab.  Got off the gurney and laid on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332262 - procedure table.  Susan used the pillow Mike had placed on the gurney,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332263 - to elevate the head on the procedure table.  This worked well to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332264 - backflow from the LESV that otherwise causes choking.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332266 -  ..
332267 - Mike, Susan, and two other women did patient preparation for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332268 - catheterization.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332270 -  ..
332271 - IV in right arm was connected to infuse medications - fentanyl and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332272 - versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332274 -  ..
332275 - Mike tried to draw blood from the right arm IV, but this failed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332276 - They decided to draw blood from the left wrist IV after it is set for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332277 - the catheterization.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332279 -  ..
332280 - Someone said 1 mg of versed will be injected.  Explained limitations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332281 - on versed to avoid exceeding 5 mg, due to stroke getting versed 6 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332282 - for EGD procedure on 160617 1637. ref SDS 35 5F6F  Have good response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332283 - geting normally only 3 infusions of versed in 1 mg increments over 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332284 - - 15 minute EGD procedures.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332286 -  ..
332287 - During this setup, Cynthia came in and wished everyone good luck,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332288 - saying she will be in the Control Room, watching the procedure and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332289 - diagnostics, implementing planning on 200123 0419. ref SDS E3 MG6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332291 -  ..
332292 - Everyone seemed to know she is working with Doctor Shunk on clinical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332293 - studies.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332295 -  ..
332296 - Susan did most of the preparation for left hand and arm where catheter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332297 - will enter for the procedure.  Malisa worked on the right side to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332298 - prepare the groin, in case problems occur advancing the catheter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332299 - through the left hand entry.  Laura backed up Susan and the other                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332300 - woman, collaborating on procedures and protocols.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332302 -  ..
332303 - Pain developed laying the left knee flat on the procedure table.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332304 - Mike placed a pillow under both knees.  This solved the problem.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332306 -  ..
332307 - Extensive procedures and coverings were used to prevent infection.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332309 -  ..
332310 - Left hand and forearm were thoroughly washed and treated with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332311 - greenish-blue disinfectant.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332313 -  ..
332314 - Two insertion locations were preapred on the left wrist, so if 1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332315 - fails, they can immediately try the 2nd.  If both fail, they will use                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332316 - groin entry.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332318 -  ..
332319 - Malisa placed a surgical glove to just above the fingers of the left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332320 - hand.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332322 -  ..
332323 - Malisa wrapped the left hand with blue cloth that had adhesive to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332324 - maintain in place during the procedure.  Had to wholed left arm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332325 - vertical at the elbow during this prolonged process of wraping with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332326 - blue protective cloth.  Susan held the left arm in place during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332327 - placement of the blue cloth wrapping.  She gave detailed instructions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332328 - to the woman who did the wrapping.  There was an impression the woman                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332329 - was getting on-the-job training.  Susan said this part was done                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332330 - correctly.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332332 -  ..
332333 - Entire body was drapped with clear plastic covering.  Then a warm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332334 - blanket was laid over that.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332336 -  ..
332337 - In all, preparations were extensive.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332339 -  ..
332340 - Doctor Jeremy Tietjens arrived.  Standing on left side he explained                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332341 - the work plan for cardiac IVUS catheterization angiography.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332343 -  ..
332344 - He moved to the right side.  Large screen monitor was rolled up to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332345 - the left side.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332347 -  ..
332348 - Doctor Tietjens gave the order to infuse fentanyl and then versed 1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332349 - mg.  Think Susan did the infusions in the right arm catheter.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332350 - began the cardiac catheterization angigram ordered by Doctor Simpson                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332351 - to investigate for failed bypass graft, reported on 200108 1130.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332352 - ref SDS C8 UV3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332354 -  ..
332355 - Seemed like the doctor asked what kind of music I like.  As 10 years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332356 - before, said Simon and Garfunkle, reported on 091021 0716. ref SDS 7                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332357 - 7L71  He said we can do that.  This music came over the speaker system                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332358 - for the rest of the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332360 -  ..
332361 - There was injection in the left wrist area.  This initially stung a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332362 - little.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332364 -  ..
332365 - Became quite groggy from the versed, so had problems following the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332366 - rest of the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332368 -  ..
332369 - Felt pain level 5 at times in the left arm.  The doctor ordered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332370 - additional fentanyl.  This eased left arm pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332372 -  ..
332373 - At the end, Doctor Tietjens seemed excited walking back and forth next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332374 - to the right side of the procedure table.  He was saying loudly that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332375 - all of the bypass grafts are completely clear.  There is no plaque                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332376 - buildup of any amount.  The saphenous vein grafts are in very good                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332377 - condition 10 years after CABG x4 on 091022 0700. ref SDS 8 PQWU  It is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332378 - the best result he has ever seen.  He said you must keep doing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332379 - whatever you have been doing to achieve this amazing result.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332380 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332381 -               [On 230919 1230 progress notes by Doctor Iannuzzi                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332382 -               reports CT on 2308__ indicates "aorta appears to have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332383 -               irregularity consistent with complex aortic plaque vs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332384 -               focal dissection." ref SDS G3 NL48                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332386 -  ..
332387 - Was able to tug the doctor's sleeve, even though my arms were secured.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332388 - Asked the doctor to put this result and recommendation in his progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332389 - notes.  He smiled and agreed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332390 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332391 -               [...below on 200124 0705 Doctor Tietjens' progress notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332392 -               report 0% stenosis, which means blood vessels are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332393 -               "completely clear", ref SDS 0 5G59, as he said during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332394 -               procedure; and further say in addendum patient continue                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332395 -               doing whatever has been doing to achieve good results.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332396 -               ref SDS 0 5X8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332398 -                ..
332399 -               [On 200128 0730 during IVUS procedure placing stent,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332400 -               Doctor Shunk commented extremely favorable finding blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332401 -               vessels completely clear of plaque 10 years after CABG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332402 -               x4. ref SDS F2 Y65N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332404 -  ..
332405 - IVUS finding completely clear blood vessels today, 11 years after CABG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332406 - x4, and after raising HDL 30 at that time, to HDL 83 on 181112 1720.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332407 - ref SDS 81 N64J, suggests reverse cholesterol transport (RCT) occurred                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332408 - from raising both HDL and EPCs to therapeautic levels, proposed in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332409 - article on 131125 0005. ref SDS 20 P46K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332411 -  ..
332412 - Doctor Tietjens asked about patient hiking and HDL?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332414 -  ..
332415 - Explained it's the combination of HDL and EPCs.  From 2003 to 2009                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332416 - hiked with Millie 3 - 8 miles a day and 4 - 6 times per week to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332417 - maintain her blood counts (ANC) for cancer treatments, prescribed at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332418 - Kaiser on 030606 1630. ref SDS 1 X55N).  This effort enabled Millie,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332419 - diagnosed with stage 4 cancer (IBC), to live nearly 10 years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332420 - However, it produced only HDL 30 for Welch, leading to CABG x4 on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332421 - 091022. ref SDS 8 PQWU  Research reported in the record on 131125                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332422 - 0005, indicated elevated HDL and EPCs regress plaque, and that hiking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332423 - increases both. ref SDS 20 RA7K  Therefore, increased hiking to 11                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332424 - miles per day - often 7 days a week.  The past 2 years, increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332425 - hiking to 20+ miles per day - see spreadsheet...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332426 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332427 -              F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332429 -  ..
332430 - Recovery from CAD/CVD and atherosclerosis, increased blood flow with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332431 - "completely clear" blood vessels seems to have yielded other medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332432 - benefits due to increased oxygen and nutrients to cells...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332433 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332434 -        1.  Presbyopia - vision recovered after 20 years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332435 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332436 -        2.  Distance vision slightly improved, but stable compared to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332437 -            test a year earlier, so do not need upgrade glasses with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332438 -            stronger lenses at age 77, reported on 220406 0900.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332439 -            ref SDS G2 6X40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332441 -             ..
332442 -        3.  Hearing was later reported improved on 220127, compared to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332443 -            prior test 5 years earlier in 2017. ref SDS F9 568F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332445 -             ..
332446 -        4.  Achalasia - swallowing recovered, reported a year later in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332447 -            barium swallow test on 211021 0715. ref SDS F8 SL46                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332449 -             ..
332450 -        5.  Sarcopenia deferred - maintain energy and strength at age                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332451 -            75 - hiked Half Dome at age 73.  Daily hiking mileage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332452 -            increased from 5 miles per day, to 11, and recently to 20;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332453 -            see study in spreadsheet...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332454 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332455 -              F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332457 -             ..
332458 -        6.  Cognition - maintain alertness and function                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332460 -             ..
332461 -        7.  Atherosclerosis controlled by elevated HDL causing 0%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332462 -            stenosis in IVUS today, so no rush to replace Atorvastitin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332463 -            when statins causing left shoulder myopathy, peripheral                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332464 -            neuropathy, and neck pain discussed with Doctor Grunfeld in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332465 -            Endocrinology on 220127 1100, ref SDS G0 IH8M, and cited in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332466 -            letter to Doctor Pellegrini on 220130 0048. ref SDS G1 LC40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332468 -                ..
332469 -               [...below on 200124 0705 Doctor Tietjens' progress notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332470 -               report 0% stenosis, which means blood vessels are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332471 -               "completely clear", ref SDS 0 5G59, as he said during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332472 -               procedure; and further say in addendum patient continue                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332473 -               doing whatever has been done to achieve good results.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332474 -               ref SDS 0 5X8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332476 -                ..
332477 -               [On 200130 1439 during follow telephone call Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332478 -               Tietjens remembered he forgot to enter expanded, highly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332479 -               favorable finding in progress notes - he will file this in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332480 -               an addendum. ref SDS F3 IS7G,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332482 -                ..
332483 -               [...below on 200124 0705 progress notes report addendum                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332484 -               entered on 200130 that his bypass grafts are all open, he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332485 -               should "keep doing what [...he...] is doing." at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332486 -               ref SDS 0 5X8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332488 -                ..
332489 -               [...below on 200124 0705 at 1438 Erron reported Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332490 -               Shunk smiled when Doctor Tietjens told him the patient has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332491 -               0 stenosis 10 years after CABG x4. ref SDS 0 T531                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332493 -                ..
332494 -               [...below on 200124 0705 at 1453 Doctor Tietjens visited in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332495 -               hospital room after the procedure.  He removed the catheter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332496 -               guide and wrapped the wrist with Coban tape. ref SDS 0 O78N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332497 -               He will for sure enter in progress notes his prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332498 -               for the patient to continue doing whatever he has been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332499 -               doing to achieve such exceptional results. ref SDS 0 6D4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332501 -                ..
332502 -               [On 200125 1825 received letter from Doctor Titus, saying                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332503 -               "fantastic news, and "big picture" is grafts remain patent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332504 -               due to healthy lifestyle, which refers to hiking.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332505 -               ref SDS E8 9C9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332507 -                ..
332508 -               [On 200221 0800 during meeting in Orthopedics, Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332509 -               Thuillier advised that PRP treatments injecting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332510 -               concentrated platelets into feet and knee injuries not only                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332511 -               generates collagen that heals wounds to prevent pain, so                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332512 -               that hiking can occur, the concentrated platelets also                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332513 -               prevent inflammation that occurs with painful injuries,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332514 -               which otherwise blocks the liver from producing HDL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332515 -               ref SDS F6 HB3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332516 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332525 -  ..
332526 - This treatment yielded HDL 83 on 181112. ref SDS 81 5C7M  In the past                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332527 - month, paroxysmal atrial fibrillation (PAF) dropped this to HDL 49 on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332528 - 200121, explained on 200103 0700. ref SDS C4 MZ37  Some authorities                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332529 - correlate PAF to continually elevated HDL, reviewed on 200103 0700.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332530 - ref SDS C4 N68K and/or to high intensity hiking, reported on 200103                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332531 - 0700. ref SDS C4 9U61  Must tailor hiking to avoid PAF and maintain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332532 - HDL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332534 -  ..
332535 - Cardiac catheterization IVUS angiography study today, aligns with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332536 - treadmill stress test finding no evidence of stenosis in blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332537 - vessels, reported on 200103 0700. ref SDS C4 TS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332539 -  ..
332540 - EKG monitoring reported no indications stenosis (ischemic).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332542 -  ..
332543 - Results today, align with CCTA test a year ago on 181108 0930,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332544 - ref SDS 80 TF3H, and also a previous CCTA performed 3 years earlier on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332545 - 151019 0930. ref SDS 27 SU62                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332547 -  ..
332548 - Doctor Tietjens said there is an 80-90% blockage in a branch vessel,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332549 - but it is unimportant in patient heart-function and overall health.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332550 - He advised that, if it was necessary to stent this blockage, he would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332551 - do it immediately, as Doctor Shunk stated during the prior angiography                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332552 - procedure on 091021 0716. ref SDS 7 2O5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332553 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332554 -            [On 200128 0730 Doctor Simpson visited after IVUS cath lab                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332555 -            procedure to place a stent in the 1st blocked branch                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332556 -            vessel, and advised the team found a 2nd blocked vessel,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332557 -            which was not cleared with a stent, because the location                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332558 -            was difficult to access, and the amount of blood it                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332559 -            provided to the heart was very small. ref SDS F1 AH42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332561 -             ..
332562 -            [On 200128 0730 progress notes for IVUS guided PCI                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332563 -            procedure placing a stent reports pre-procedure stenosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332564 -            95%; TIMI Flow: 3 - Complete flow, and Post-procedure 0%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332565 -            stenosis; TIMI Flow: 3 - Complete flow, indicating no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332566 -            improvement from placing the stent. ref SDS F1 QR4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332568 -  ..
332569 - Seems similar to bypassed native arteries, also, filled with plaque.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332570 - The calcium score was 1360 for coronary CT angiography (CCTA)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332571 - procedure on 151019 0930. ref SDS 27 SU5O  On 181108, follow up CCTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332572 - calcium score increased to 1484. ref SDS 80 CH3K  Jeremy's findings                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332573 - today, that the 4 bypassed arteries are filled with plaque, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332574 - most of the blood flows to the heart in the bypass grafts, equally                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332575 - caused this one branch vessel to fill with plaque.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332577 -  ..
332578 - It would further seem that stenting this one blocked branch vessel                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332579 - would be no more beneficial than stenting a blocked artery, since the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332580 - bypass grafts supply all the blood needed by the heart.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332582 -  ..
332583 - Asked the doctor to show on the screen imaging the location of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332584 - blocked branch.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332586 -  ..
332587 - He leaned over me and reaching with an outstretched arm pointed with a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332588 - pen or pencil to a small contrast filled blood vessel on the screen.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332590 -  ..
332591 - Still not sure if the branch vessel is from a bypass graft, native                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332592 - artery or what?  The imaging on the screen was confusing.  Since the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332593 - doctor said it is not important, did not request clarification.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332594 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332595 -            [On 200128 0730 Doctor Tietjens explained further that the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332596 -            location of the blocked branch vessel found today on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332597 -            200124, does not get normal blood flow, so it has received                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332598 -            less HDL than other blood vessels, which are not blocked.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332599 -            He further cited adhesion and shear forces that may be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332600 -            greater, which prevents regression of plaque at this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332601 -            location. ref SDS F1 OL5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332603 -  ..
332604 - Should check CCTA files to see if branch blockage was advancing in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332605 - 151019, and on 181108.  Analysts did not report this, but might be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332606 - visible in the radiology file.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332608 -            [On 200128 0730 progress notes for IVUS guided PCI                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332609 -            procedure placing a stent reports pre-procedure stenosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332610 -            95%; TIMI Flow: 3 - Complete flow, and Post-procedure 0%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332611 -            stenosis; TIMI Flow: 3 - Complete flow. ref SDS F1 QR4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332613 -  ..
332614 - Stenting 1 blocked branch vessel may be unnecessary because blockage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332615 - stimulates growth of new collateral blood vessels, and causes existing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332616 - small vessels (e.g., capillaries) to elongate, widen and form new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332617 - connections that route blood flow into the heart around the blocked                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332618 - branch vessel, explained following treadmill stress test at VA Clinic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332619 - in Martinez on 091002 0900. ref SDS 5 V44I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332621 -  ..
332622 - Doctor Tietjens seemed familiar with patient history hiking 11 - 20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332623 - miles per day, and noted this level of effort increases blood flow                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332624 - through collateral vessels that make stenting less urgent today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332626 -  ..
332627 - After the procedure, research found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332628 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332629 -    Harvard Health Publishing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332630 -    Harvard Medical School                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
332632 -     ..
332633 -    Do-it-yourself cardiac bypass surgery: All you need is walking shoes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332634 -    
332635 -    Published: January, 2008                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332636 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332637 -              https://www.health.harvard.edu/press_releases/do-it-yourself-cardiac-bypass-surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332639 -     ..
332640 -    When cholesterol-clogged plaque narrows an artery that feeds the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332641 -    heart, the body responds by trying to bulk up tiny blood vessels                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332642 -    in the heart. As these so-called collateral vessels grow more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332643 -    muscular and interconnected, they begin to reroute some of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332644 -    blood flow around the blockage.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332646 -     ..
332647 -    Exercise dramatically increases blood flow through the coronary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332648 -    arteries.  The inner lining of the arteries responds to this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332649 -    "stress" much as it does to the stress of atherosclerosis, by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332650 -    stimulating collateral blood vessels to elongate, widen, and form                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332651 -    new connections.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332653 -     ..
332654 -    ...a little bit of exercise won't do the trick.  You need to push                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332655 -    your heart.  If you aren't used to exercising, that may mean brisk                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332656 -    walking.  Any activity that gets your heart beating faster will do                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332657 -    as long as you keep it up for 20 to 30 minutes at a time and do it                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332658 -    several times a week.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
332660 -     ..
332661 -    Exercise is a great way to prevent heart disease, and a host of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332662 -    studies show that it can help some people with narrowed coronary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332663 -    arteries safely avoid bypass surgery or angioplasty.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332665 -  ..
332666 - Doctor Tietjens called and left messages for Doctor Shunk and Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332667 - Simpson, inviting them to come see exceptionally good results in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332668 - procedure today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332670 -  ..
332671 - Since Doctor Shunk and Doctor Simpson did not come to the Cath Lab nor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332672 - call back, he decided to stop work, saying another procedure can be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332673 - scheduled, if needed, to stent this branch blockage.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332675 -  ..
332676 - Thanked the doctor, and advised that his findings today, per above,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332677 - ref SDS 0 ME8G, are cogent and compelling for patient care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332679 -  ..
332680 - The large computer monitor screen was moved away from the left side.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332681 - Susan and Mike broke down the procedure setup removing all the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
332682 - wrappings applied for the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332684 -  ..
332685 - Mike wrapped the catheter access hole on the left wrist with coban                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332686 - tape.  He said to leave it wrapped for several days - not sure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332688 -  ..
332689 - Mike further said to avoid using left wrist for anything over 5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332690 - pounds for next few days - again not sure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332692 -  ..
332693 - Stepped down from the procedure table and laid back down on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332694 - gurney.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332696 -  ..
332697 - Was pushed back to the preparation room.  Mike entered more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332698 - information into the record (progress notes) to complete the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
332699 - procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332701 -  ..
332702 - Cynthia visited again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332704 -  ..
332705 - Mike went to get Kathy waiting in Cardiology across the hall.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332707 -  ..
332708 - Cynthia was her usual bubbly self offering congratulations on such                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332709 - great results.  Said it will be fun working with her in the stenting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332710 - preparation study, discussed on 200122 0423. ref SDS E2 07F5  Cynthia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
332711 - said I will not qualify for the stenting preparation study, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332712 - the blockage today, was only in a branch vessel.  The study is for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
332713 - preparing vessel walls for stents in main arteries.  Cynthia left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332714 - promising to keep in touch collaborating on future issues.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332715 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332716 -            [On 200128 0730 Cynthia visited in the hallway briefly,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332717 -            while I was being pushed on a gurney into the Cath Lab for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332718 -            the stent IVUS procedure, ref SDS F1 2S59; and, seemed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
332719 -            say I was still eligible for PCSK9 clinical trial.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332720 -            ref SDS F1 5B4K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
332722 -             ..
332723 -            [On 200204 2252 letter to Cyn asks about joining PCSK9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332724 -            study. ref SDS F4 9C9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332726 -             ..
332727 -            [On 200205 1941 received letter from Cyn saying that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332728 -            participation in PCSK9 study is not possible because some                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
332729 -            protocols were not followed. ref SDS F5 9C9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
332731 -  ..
332732 - Mike and Kathy returned.  He had told her the good news.  Kathy was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
332733 - elated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
332735 -  ..
332736 - Mike pushed me in a wheelchair again back to the room in Surge Med 2B                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
332737 - South.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
332739 -  ..
332740 - Thanked him for courtesy and terrific work today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
332741 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332742 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
332744 -  ..
3328 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3329 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3330 - 1430                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3331 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
333101 - Doctor Cara Pellegrini visited in the hospital room post-procedure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
333102 - following up prior meeting 2 days ago on 200122 0423. ref SDS E2 MN4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
333104 -  ..
333105 - She has discussed the case with Doctor Simpson and Doctor Shunk.  They                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333106 - all feel results are remarkable finding during cardiac catheterization                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333107 - totally clear bypass grafts, per above, ref SDS 0 ME8G, 10 years after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333108 - CABG x4 on 091022 0700. ref SDS 8 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
333110 -  ..
333111 - There is belief that chest pain may be multifacorial, caused by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333112 - paroxysmal atrial fibrillation and the 90% stenosis in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
333113 - posterolateral branch native vessel (not the saphenous bypass graft                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
333114 - vessels) found during cardiac catheritization angiography.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
333115 - Accordingly, Doctor Pellegrini wants to wait on meeting for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
333116 - considering pulmonary vein isolation procedure for ablation of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
333117 - paroxysmal atrial fibrilation (PAF).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
333119 -  ..
333120 - She said her assistant will call to schedule a meeting in about a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
333121 - month after the Cath Lab procedure to stent the brach artery found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
333122 - during the procedure today, per above. ref SDS 0 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
333123 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333124 -            [On 200127 0901 Carolyn called in Cardiology Department                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333125 -            Arrhythmia Clinic scheduled meeting with Doctor Pellegrini                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
333126 -            on 200219 1130. ref SDS E9 9C9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
333127 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333128 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333129 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333130 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333132 -  ..
3332 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3333 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3334 - 1438                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3335 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
333501 - Doctor Erron Titus visited.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
333502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333503 - He confirmed favorable findings from Cath Lab today, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333504 - ref SDS 0 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
333506 -  ..
333507 - Erron seemed to say he joined the meeting with Doctor Tietjens                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
333508 - reporting results of the procedure to Doctor Shunk and Doctor Simpson.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333510 -  ..
333511 - Erron said Doctor Shunk smiled, when Doctor Tietjens explained finding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333512 - bypass grafts completely clear with 0 stenosis 10 years after CABG x4,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333513 - and that he told the patient to continue doing whatever he is doing to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333514 - get such great results, per above. ref SDS 0 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
333515 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333516 -            [On 200128 0730 during IVUS procedure placing stent, Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
333517 -            Shunk commented extremely favorable finding blood vessels                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
333518 -            completely clear of plaque 10 years after CABG x4.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
333519 -            ref SDS F2 Y65N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
333521 -  ..
333522 - Doctor Shunk's smile, may relate to discussions a few days ago about                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
333523 - studying benefits of raising HDL to regress atherosclerotic plaque,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
333524 - reported on 200122 0423. ref SDS E2 PR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
333526 -  ..
333527 - Erron advised that Doctor Simpson and Doctor Shunk want to stent the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
333528 - partially blocked, branch vessel, despite minimal risk for causing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
333529 - chest pain suffered the past few weeks after onset of paroxysmal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
333530 - atrial fibrillation (PAF), findings above. ref SDS 0 5J8O  Erron                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
333531 - understands there is a feeling that some unknown interaction between                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
333532 - the blockage and PAF can be resolved by stenting to prevent PAF pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
333533 - If pain continues after stenting, and while continuing drug therapy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
333534 - for a month, this would justify considering pulmonary vein isolation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
333535 - ablation to resolve PAF, explained in the record on 191206 1425.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
333536 - ref SDS A9 1143                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
333537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333538 -            [On 200127 1001 letter asks to be admitted the day before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
333539 -            Cath Lab on 200128, in order to avoid driving to the VA at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
333540 -            0200 for procedure at 0730. ref SDS F0 CZ34                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
333542 -             ..
333543 -            [On 200128 0730 after the IVUS procedure was performed, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
333544 -            in recovery research found an article, "IVUS in PCI                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
333545 -            Guidance," on when a lesion is significant enough, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
333546 -            ischemia producing, and therefore should be treated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333547 -            ref SDS F1 TS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
333549 -  ..
333550 - Placing stent on the branch vessel that does not contribute to patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333551 - health, cited by Doctor Tietjens, per above, ref SDS 0 5J8O, may have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
333552 - been decided to expand patient monitoring profile in cardiology.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333553 - could just as easily be accomplished by stenting a native bypassed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
333554 - artery, per above. ref SDS 0 0V6G  Expect Cardiology will promote                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
333555 - increased statins and other meds, e.g., aspirin, to meet department                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
333556 - protocols.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
333558 -  ..
333559 - Will have to consider effect of increased Metoprolol Tartrate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
333560 - treatment prescribed yesterday, to reduce heart rate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
333562 -  ..
333563 - Erron advised that Cardiac catheterization on 200128 0730 is still                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
333564 - scheduled in the Cath Lab, so they want to do the procedure at that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
333565 - time.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
333567 -  ..
333568 - Apixaban should continue paused until after that procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
333570 -  ..
333571 - We decided to avoid strenuous hikes until after Cath Lab on 200128.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
333573 -  ..
333574 - Patient needs to begin taking a new blood thinner medication...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333575 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333576 -            Clopidogrel Bisulfate (Plavix) 75 MG tablet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333577 -            Take 1 pill every day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
333579 -  ..
333580 - Erron explained this is needed while trauma heals in the blood vessels                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333581 - from the procedure today, and again on next Tuesday on 200128.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
333583 -  ..
333584 - This blood thinner treatmente should continue through 200128.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
333586 -  ..
333587 - Not sure how long this treatment should continue for Clopidogrel??                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
333588 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333589 -            [On 200125 0418 letter asks Erron how long to take                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
333590 -            Clopidogrel? ref SDS E6 PA36                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
333591 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333592 -            [On 200125 1825 Erron letter says to take Clopidogrel for a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
333593 -            year after the procedure. ref SDS E8 BM33                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
333594 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333595 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333596 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333598 -  ..
3336 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3337 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3338 - 1453                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3339 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
333901 - Doctor Jeremy Tietjens visited.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333902 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333903 - He removed the catheter guide for the procedure today, and wrapped the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333904 - wound with gauze and corban tape.  Said the wrap can be removed in a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
333905 - few days.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
333907 -  ..
333908 - The wrap was actually too tight, but did not mention this to Jeremy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
333910 -  ..
333911 - Thanked the doctor for good work today, and reporting favorable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333912 - findings during the procedure, per above. ref SDS 0 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
333914 -  ..
333915 - Doctor Tietjens said he will for sure enter his prescription in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333916 - progress notes for the patient to continue doing whatever he has been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
333917 - doing to achieve such exceptional results found in angiography this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
333918 - morning, per above. ref SDS 0 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
333919 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333920 -            [On 200130 1439 during follow telephone call Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
333921 -            Tietjens remembered he forgot to enter expanded, highly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
333922 -            favorable finding in progress notes - he will file this in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
333923 -            an addendum. ref SDS F3 IS7G,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
333925 -             ..
333926 -            [...below on 200124 0705 progress notes report addendum                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
333927 -            entered on 200130 that his bypass grafts are all open, he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
333928 -            should "keep doing what [...he...] is doing." at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
333929 -            ref SDS 0 5X8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
333930 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333931 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333932 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
333934 -  ..
3340 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3341 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3342 - 1501                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3343 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
334301 - Iris visited from the Pharmacy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
334302 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
334303 - She delivered several medicines.  The ones we need are...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
334304 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
334305 -            Clopidogrel Bisulfate (Plavix) 75 MG tablet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
334306 -            Take 1 pill every day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
334308 -             ..
334309 -            Metorpolol Tartrate 25 MG tablet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
334310 -            Take .5 table twice a day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
334312 -  ..
334313 - Clopidogrel Bisulfate (Plavix) is a blood thinner to treat the blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
334314 - vessels traumatized during cardiac catheritization angiography                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
334315 - performed this morning, per above. ref SDS 0 5F5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
334317 -  ..
334318 - Iris has ordered Ensure to be shipped to the house, that aids                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
334319 - digestion treating achalasia.  She will discuss with the nutritionist,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
334320 - Gary Yee, ordering 2 refills, as done previously on 190529 1023.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
334321 - ref SDS 96 UJ5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
334322 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
334323 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
334325 -  ..
3344 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3345 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3346 - 1548                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3347 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
334701 - Angilica took last vitals and said we are checked out to return home.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
334702 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
334703 - Leaving 2B South, saw Cynthia again in the hallway.  She was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
334704 - disappointed there were no blockages found in the bypass grafts, which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
334705 - would qualify for entering in the 2 clinical trials.  She offered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
334706 - generous contragulations on siginficant findings having no plaque in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
334707 - bypass grafts after 10 years.  She said that is truly remarkable.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
334708 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
334709 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
334710 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
3348 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
3403 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
340401 -  ..
340402 - Progress Notes Cardiac Catheterization Evaluate Plaque 10 Years After CABG x4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
340403 - 
340405 -  ..
340406 - Request records on CD from ROI for this medical encounter due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340407 - continual difficulties downloading medical records from VA website                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
340408 - at...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340409 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340410 -              https://www.myhealth.va.gov/mhv-portal-web/track-health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340411 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340418 -  ..
340419 - Stored Progess Notes for procedure on 200124 at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340420 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340421 -              F:\05\00003\SM\CC\AGMJ\20200124-070500\mhv_WELCH_20200202_1409.txt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340422 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340423 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340424 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340425 -        Date/Time:               24 Jan 2020 @ 1437                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
340426 -        Note Title:              CARDIAC CATHETERIZATION REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
340427 -        Location:                San Francisco CA VAMC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340428 -        Signed By:               TIETJENS,JEREMY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340429 -        Co-signed By:            TIETJENS,JEREMY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340430 -        Date/Time Signed:        24 Jan 2020 @ 1437                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
340431 -        -------------------------------------------------------------------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340433 -         ..
340434 -        LOCAL TITLE: CARDIAC CATHETERIZATION REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
340435 -        STANDARD TITLE: CARDIOLOGY CONSULT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
340436 -        DATE OF NOTE: JAN 24, 2020@14:37     ENTRY DATE: JAN 24, 2020@14:37:30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
340437 -        AUTHOR: TIETJENS,JEREMY      EXP COSIGNER: CHOU,TONY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340438 -        URGENCY:                            STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
340439 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340440 -        *** CARDIAC CATHETERIZATION REPORT Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
340442 -         ..
340443 -        The following is a preliminary report unless cosigned by a Staff or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
340444 -        Attending Physician.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340446 -         ..
340447 -        VA CART Program for Clinical Assessment, Reporting, and Tracking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
340448 -                        CART-CATH:066200-00389F15-CDS0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340450 -         ..
340451 -        CARDIOVASCULAR DIAGNOSTIC AND THERAPEUTIC PROCEDURE REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340453 -         ..
340454 -        Patient: WELCH,RODNEY CHARLES  SSN:  561720144  DOB:   3/1/1945  AGE: 74                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340456 -         ..
340457 -        Procedure Date: 01/24/2020  Associated Assessment: 1/23/2020  Case: 2020-0063                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340458 -        Attending: CHOU,TONY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340459 -        Assisting: TIETJENS,JEREMY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340461 -         ..
340462 -        Diagnostic Procedures:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
340463 -          Coronary Angiography, Bypass Graft Angiography                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
340464 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340465 -         Status: Elective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340466 -         This was an inpatient procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340467 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340468 -         Type of procedure, site, and patient ID were verified with the patient.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340469 -         Re-assessment was performed immediately prior to conscious sedation and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340470 -          no change was noted.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
340471 -         NPO status greater than 4 hours verified.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340472 -         The attending was present throughout the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340474 -         ..
340475 -        Indications: Stable Angina or equivalent, Arrhythmia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340477 -         ..
340478 -        ACCESS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
340479 -         Primary Arterial:   Left Distal Radial, 6F sheath, Radial Hemostasis closure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340481 -         ..
340482 -        CATHETERS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340483 -         Right coronary artery: JR 4, 6 fr                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
340484 -         Left coronary artery:  JL 3.5, 6 fr                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340485 -        , 6 fr, IMA (LIMA), JR 4 (SVG-RCA and SVG-ramus), LCB (SVG-D1)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340486 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340487 -          Aorta:       121/ 69, mean  89                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
340489 -         ..
340490 -        CORONARY ANGIOGRAPHY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340491 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340492 -        --------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340493 -        Native Vessels                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340494 -        --------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340495 -        Summary:   Other - see comments                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
340496 -        Dominance: Right dominant                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340498 -         ..
340499 -        Narrative Description:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
340500 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340501 -          Left main coronary artery (LMCA): The LMCA is a large caliber vessel that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
340502 -          arises from the left sinus of Valsalva and gives rise to the left anterior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340503 -          descending (LAD), ramus intermedius (RI) and left circumflex (LCx) arteries.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340504 -          The LMCA contains no angiographically significant disease.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340506 -  ..
340507 - Seems to mean stenosis 0 - widely patent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340508 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340509 -          LAD: The LAD is a large caliber vessel that gives rise to two diagonal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340510 -          branches (large bifurcating D1 and medium D2) and septal perforators before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340511 -          wrapping the apex. The proximal LAD is 100% occluded, and the mid to distal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340512 -          LAD fill via patent LIMA graft. D2 backfills via LIMA. There is a widely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340513 -          patnet SVG that supplies both limbs of the D1 branch.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
340515 -  ..
340516 - Seems to mean stenosis 0 - widely patent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340518 -           ..
340519 -          LCx: The LCx is a medium caliber, non-dominant vessel that gives rise to one                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340520 -          obtuse marginal branches OM 1 as it courses within the AV groove. There are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340521 -          mild luminal irregularities in the LCx system, which overall does not supply                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340522 -          substantial territory.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340524 -           ..
340525 -          Ramus: The RI branch is 95% blocked proximally and fills via a patent SVG.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340527 -           ..
340528 -          Right coronary artery (RCA): The RCA is a large caliber vessel that gives                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
340529 -          rise to an acute marginal branch before giving off the posterior descending                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340530 -          artery (PDA) and a right posterolateral (RPL) system at the level of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340531 -          crux. The RCA is severely diseased with serial 90% stenosis along its length.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
340532 -          The PDA fills via a patent SVG. There is a 95% stenosis in the proximal rPL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340533 -          branch.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340535 -         ..
340536 -        BYPASS GRAFT ANGIOGRAPHY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340538 -        -------------------------------------------------------------------------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
340539 -           Graft      Stenosis Length Insertion Segment   Characteristics                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340540 -        -------------------------------------------------------------------------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
340541 -        1. Pedicle LIMA               Mid LAD             Normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340542 -        2. SVG                        Right PDA           Normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340543 -        3. SVG                        1st Diagonal        Normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340544 -        4. SVG                        Ramus Intermedius   Normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340545 -        -------------------------------------------------------------------------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
340546 -          note: Stenosis = highest % stenosis within segment                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340548 -             ..
340549 -            [...above on 200124 0705 at 1430 0 stenosis length means                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
340550 -            blood vessels are "completely clear" as Doctor Tietjens                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
340551 -            reported during the procedure this morning, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340552 -            ref SDS 0 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
340554 -             ..
340555 -            [...below on 200124 0705 "Recommendations" do not say                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340556 -            patient continue doing whatever he has been doing to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340557 -            achieve such good results with stenosis 0 now 10 years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340558 -            after CABG x4. ref SDS 0 5G42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340560 -             ..
340561 -            [On 200128 0730 during IVUS procedure placing stent, Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
340562 -            Shunk commented extremely favorable finding blood vessels                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340563 -            completely clear of plaque 10 years after CABG x4.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
340564 -            ref SDS F2 Y65N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340565 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340573 -             ..
340574 -            [On 220127 0900 testing found hearing improved compared to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
340575 -            prior test 5 years earlier in 2017. ref SDS F9 568F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340577 -             ..
340578 -            [On 220406 0900 examination in Vision Clinic found distance                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
340579 -            vision slight improvement, but stable, so do not need                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340580 -            upgrade glasses with stronger lenses at age 77. ref SDS G2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340581 -            6X40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340582 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340584 -         ..
340585 -        IN-LAB MEDICATIONS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
340586 -         Fentanyl                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340587 -         Heparin (Unfractionated) 5000 IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340588 -         Lidocaine SC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340589 -         Midazolam                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340590 -         Nicardipine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340591 -         Nitroglycerin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340593 -         ..
340594 -        Start of procedure: 01/24/2020 09:00    End of procedure: 01/24/2020 10:07                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340595 -        Summary Data:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340596 -          Total Contrast: 200 mL, Visipaque-320 (iodixanol)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
340597 -          Total Fluoroscopy Time: 13 min                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
340598 -          Radiation DAP: 97.13 dGy-cm2  Air Kerma: 774 mGy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
340599 -          Total Fluids: 350 mL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
340600 -          Estimated Blood Loss: 5 mL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340601 -          Specimen removed: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
340603 -         ..
340604 -        COMPLICATIONS IN LAB                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340605 -         No Major Adverse Events or Complications                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340607 -         ..
340608 -        FINAL DIAGNOSIS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
340609 -        1) Severe native vessel coronary artery disease as outlined above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
340610 -        2) Widely patent LIMA graft to LAD, and patent SVGs to ramus, diagonal and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340611 -        PDA.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340612 -        3) Severe 95% stenosis of the rPL branch, not bypassed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
340614 -         ..
340615 -        RECOMMENDATIONS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
340616 -        1) Optimal medical therapy for stable angina per current ACC/AHA guidelines.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340617 -        2) Plan to bring back for elective PCI of the rPL branch on Tuesday.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
340618 -        3) Radar band x2 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
340619 -        4) Ok to discharge later today from cardiac perspective.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340621 -  ..
340622 - During the procedure Doctor Tietjens recommended the patient continue                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340623 - doing whatever he has been doing to achieve such exceptionally good                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340624 - results with 0 stenosis, shown above, ref SDS 0 5G59, and saphenous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340625 - veins in very good condition, now 10 years after CABG x4, and that he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340626 - would include this in his progress notes, per above. ref SDS 0 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340628 -  ..
340629 - Progress Notes continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
340630 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340631 -        /es/ Jeremy Tietjens, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340632 -        Interventional Fellow, Cardiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340633 -        Signed: 01/24/2020 14:37                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340634 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340635 -        /es/ Tony M. Chou, M.D.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
340636 -        Interventional Cardiology Attending 95163                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340637 -        Cosigned: 01/24/2020 14:49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340639 -         ..
340640 -        01/30/2020 ADDENDUM                      STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340641 -        Per discussion with patient following diagnostic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
340642 -        catheterization, namely that his bypass grafts are all open,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340643 -        he should "keep doing what [...he...] is doing."                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
340644 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340645 -            [On 200128 0730 during IVUS procedure placing stent, Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
340646 -            Shunk commented extremely favorable finding blood vessels                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
340647 -            completely clear of plaque 10 years after CABG x4.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
340648 -            ref SDS F2 Y65N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340650 -  ..
340651 - This implements findings at the end of cardiac catheteritization                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340652 - angiogram, that all of the bypass grafts are completely clear.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340653 - is no plaque buildup of any amount.  The saphenous vein grafts are in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
340654 - very good condition 10 years after CABG x4 on 091022 0700. ref SDS 8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
340655 - PQWU  It is the best result he has ever seen, and recommend patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
340656 - continue doing whatever he is doing to achieve this exceptionally good                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
340657 - result." ref SDS 0 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
340658 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340659 -        /es/ Jeremy Tietjens, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340660 -        Interventional Fellow, Cardiology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
340661 -        Signed: 01/30/2020 14:52                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340662 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340663 -        /es/ Tony M. Chou, M.D.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
340664 -        Interventional Cardiology Attending 95163                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
340665 -        Cosigned: 02/07/2020 10:28                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
340666 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340667 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340668 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340669 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340670 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340671 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340672 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340673 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340674 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
340675 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
3407 -