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 hold 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 looking up at the
332375 - ceiling and saying loudly that all of the bypass grafts are completely
332376 - clear. There is no plaque buildup of any amount. The saphenous vein
332377 - grafts are in very good condition 10 years after CABG x4 on 091022
332378 - 0700. ref SDS 8 PQWU It is the best result he has ever seen. He said
332379 - you must keep doing whatever you have been doing to achieve this
332380 - amazing result.
332381 -
332382 - [On 230919 1230 progress notes by Doctor Iannuzzi
332383 - reports CT on 2308__ indicates "aorta appears to have
332384 - irregularity consistent with complex aortic plaque vs
332385 - focal dissection." ref SDS G3 NL48
332387 - ..
332388 - Was able to tug the doctor's sleeve, even though my arms were secured.
332389 - Asked the doctor to put this result and recommendation in his progress
332390 - notes. He smiled and agreed.
332391 -
332392 - [...below on 200124 0705 Doctor Tietjens' progress notes
332393 - report 0% stenosis, which means blood vessels are
332394 - "completely clear", ref SDS 0 5G59, as he said during the
332395 - procedure; and further say in addendum patient continue
332396 - doing whatever has been doing to achieve good results.
332397 - ref SDS 0 5X8N
332399 - ..
332400 - [On 200128 0730 during IVUS procedure placing stent,
332401 - Doctor Shunk commented extremely favorable finding blood
332402 - vessels completely clear of plaque 10 years after CABG
332403 - x4. ref SDS F2 Y65N
332405 - ..
332406 - IVUS finding completely clear blood vessels today, 11 years after CABG
332407 - x4, and after raising HDL 30 at that time, to HDL 83 on 181112 1720.
332408 - ref SDS 81 N64J, suggests reverse cholesterol transport (RCT) occurred
332409 - from raising both HDL and EPCs to therapeautic levels, proposed in the
332410 - article on 131125 0005. ref SDS 20 P46K
332412 - ..
332413 - Doctor Tietjens asked about patient hiking and HDL?
332415 - ..
332416 - Explained it's the combination of HDL and EPCs. From 2003 to 2009
332417 - hiked with Millie 3 - 8 miles a day and 4 - 6 times per week to
332418 - maintain her blood counts (ANC) for cancer treatments, prescribed at
332419 - Kaiser on 030606 1630. ref SDS 1 X55N). This effort enabled Millie,
332420 - diagnosed with stage 4 cancer (IBC), to live nearly 10 years.
332421 - However, it produced only HDL 30 for Welch, leading to CABG x4 on
332422 - 091022. ref SDS 8 PQWU Research reported in the record on 131125
332423 - 0005, indicated elevated HDL and EPCs regress plaque, and that hiking
332424 - increases both. ref SDS 20 RA7K Therefore, increased hiking to 11
332425 - miles per day - often 7 days a week. The past 2 years, increased
332426 - hiking to 20+ miles per day - see spreadsheet...
332427 -
332428 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
332430 - ..
332431 - Recovery from CAD/CVD and atherosclerosis, increased blood flow with
332432 - "completely clear" blood vessels seems to have yielded other medical
332433 - benefits due to increased oxygen and nutrients to cells...
332434 -
332435 - 1. Presbyopia - vision recovered after 20 years.
332436 -
332437 - 2. Distance vision slightly improved, but stable compared to
332438 - test a year earlier, so do not need upgrade glasses with
332439 - stronger lenses at age 77, reported on 220406 0900.
332440 - ref SDS G2 6X40
332442 - ..
332443 - 3. Hearing was later reported improved on 220127, compared to
332444 - prior test 5 years earlier in 2017. ref SDS F9 568F
332446 - ..
332447 - 4. Achalasia - swallowing recovered, reported a year later in
332448 - barium swallow test on 211021 0715. ref SDS F8 SL46
332450 - ..
332451 - 5. Sarcopenia deferred - maintain energy and strength at age
332452 - 75 - hiked Half Dome at age 73. Daily hiking mileage
332453 - increased from 5 miles per day, to 11, and recently to 20;
332454 - see study in spreadsheet...
332455 -
332456 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
332458 - ..
332459 - 6. Cognition - maintain alertness and function
332461 - ..
332462 - 7. Atherosclerosis controlled by elevated HDL causing 0%
332463 - stenosis in IVUS today, so no rush to replace Atorvastitin
332464 - when statins causing left shoulder myopathy, peripheral
332465 - neuropathy, and neck pain discussed with Doctor Grunfeld in
332466 - Endocrinology on 220127 1100, ref SDS G0 IH8M, and cited in
332467 - letter to Doctor Pellegrini on 220130 0048. ref SDS G1 LC40
332469 - ..
332470 - [...below on 200124 0705 Doctor Tietjens' progress notes
332471 - report 0% stenosis, which means blood vessels are
332472 - "completely clear", ref SDS 0 5G59, as he said during the
332473 - procedure; and further say in addendum patient continue
332474 - doing whatever has been done to achieve good results.
332475 - ref SDS 0 5X8N
332477 - ..
332478 - [On 200130 1439 during follow telephone call Doctor
332479 - Tietjens remembered he forgot to enter expanded, highly
332480 - favorable finding in progress notes - he will file this in
332481 - an addendum. ref SDS F3 IS7G,
332483 - ..
332484 - [...below on 200124 0705 progress notes report addendum
332485 - entered on 200130 that his bypass grafts are all open, he
332486 - should "keep doing what [...he...] is doing." at
332487 - ref SDS 0 5X8N
332489 - ..
332490 - [...below on 200124 0705 at 1438 Erron reported Doctor
332491 - Shunk smiled when Doctor Tietjens told him the patient has
332492 - 0 stenosis 10 years after CABG x4. ref SDS 0 T531
332494 - ..
332495 - [...below on 200124 0705 at 1453 Doctor Tietjens visited in
332496 - hospital room after the procedure. He removed the catheter
332497 - guide and wrapped the wrist with Coban tape. ref SDS 0 O78N
332498 - He will for sure enter in progress notes his prescription
332499 - for the patient to continue doing whatever he has been
332500 - doing to achieve such exceptional results. ref SDS 0 6D4G
332502 - ..
332503 - [On 200125 1825 received letter from Doctor Titus, saying
332504 - "fantastic news, and "big picture" is grafts remain patent
332505 - due to healthy lifestyle, which refers to hiking.
332506 - ref SDS E8 9C9M
332508 - ..
332509 - [On 200221 0800 during meeting in Orthopedics, Doctor
332510 - Thuillier advised that PRP treatments injecting
332511 - concentrated platelets into feet and knee injuries not only
332512 - generates collagen that heals wounds to prevent pain, so
332513 - that hiking can occur, the concentrated platelets also
332514 - prevent inflammation that occurs with painful injuries,
332515 - which otherwise blocks the liver from producing HDL.
332516 - ref SDS F6 HB3G
332517 -
332523 -
332524 -
332526 - ..
332527 - This treatment yielded HDL 83 on 181112. ref SDS 81 5C7M In the past
332528 - month, paroxysmal atrial fibrillation (PAF) dropped this to HDL 49 on
332529 - 200121, explained on 200103 0700. ref SDS C4 MZ37 Some authorities
332530 - correlate PAF to continually elevated HDL, reviewed on 200103 0700.
332531 - ref SDS C4 N68K and/or to high intensity hiking, reported on 200103
332532 - 0700. ref SDS C4 9U61 Must tailor hiking to avoid PAF and maintain
332533 - HDL.
332535 - ..
332536 - Cardiac catheterization IVUS angiography study today, aligns with
332537 - treadmill stress test finding no evidence of stenosis in blood
332538 - vessels, reported on 200103 0700. ref SDS C4 TS6L
332540 - ..
332541 - EKG monitoring reported no indications stenosis (ischemic).
332543 - ..
332544 - Results today, align with CCTA test a year ago on 181108 0930,
332545 - ref SDS 80 TF3H, and also a previous CCTA performed 3 years earlier on
332546 - 151019 0930. ref SDS 27 SU62
332548 - ..
332549 - Doctor Tietjens said there is an 80-90% blockage in a branch vessel,
332550 - but it is unimportant in patient heart-function and overall health.
332551 - He advised that, if it was necessary to stent this blockage, he would
332552 - do it immediately, as Doctor Shunk stated during the prior angiography
332553 - procedure on 091021 0716. ref SDS 7 2O5M
332554 -
332555 - [On 200128 0730 Doctor Simpson visited after IVUS cath lab
332556 - procedure to place a stent in the 1st blocked branch
332557 - vessel, and advised the team found a 2nd blocked vessel,
332558 - which was not cleared with a stent, because the location
332559 - was difficult to access, and the amount of blood it
332560 - provided to the heart was very small. ref SDS F1 AH42
332562 - ..
332563 - [On 200128 0730 progress notes for IVUS guided PCI
332564 - procedure placing a stent reports pre-procedure stenosis
332565 - 95%; TIMI Flow: 3 - Complete flow, and Post-procedure 0%
332566 - stenosis; TIMI Flow: 3 - Complete flow, indicating no
332567 - improvement from placing the stent. ref SDS F1 QR4M
332569 - ..
332570 - Seems similar to bypassed native arteries, also, filled with plaque.
332571 - The calcium score was 1360 for coronary CT angiography (CCTA)
332572 - procedure on 151019 0930. ref SDS 27 SU5O On 181108, follow up CCTA
332573 - calcium score increased to 1484. ref SDS 80 CH3K Jeremy's findings
332574 - today, that the 4 bypassed arteries are filled with plaque, because
332575 - most of the blood flows to the heart in the bypass grafts, equally
332576 - caused this one branch vessel to fill with plaque.
332578 - ..
332579 - It would further seem that stenting this one blocked branch vessel
332580 - would be no more beneficial than stenting a blocked artery, since the
332581 - bypass grafts supply all the blood needed by the heart.
332583 - ..
332584 - Asked the doctor to show on the screen imaging the location of the
332585 - blocked branch.
332587 - ..
332588 - He leaned over me and reaching with an outstretched arm pointed with a
332589 - pen or pencil to a small contrast filled blood vessel on the screen.
332591 - ..
332592 - Still not sure if the branch vessel is from a bypass graft, native
332593 - artery or what? The imaging on the screen was confusing. Since the
332594 - doctor said it is not important, did not request clarification.
332595 -
332596 - [On 200128 0730 Doctor Tietjens explained further that the
332597 - location of the blocked branch vessel found today on
332598 - 200124, does not get normal blood flow, so it has received
332599 - less HDL than other blood vessels, which are not blocked.
332600 - He further cited adhesion and shear forces that may be
332601 - greater, which prevents regression of plaque at this
332602 - location. ref SDS F1 OL5F
332604 - ..
332605 - Should check CCTA files to see if branch blockage was advancing in
332606 - 151019, and on 181108. Analysts did not report this, but might be
332607 - visible in the radiology file.
332608 -
332609 - [On 200128 0730 progress notes for IVUS guided PCI
332610 - procedure placing a stent reports pre-procedure stenosis
332611 - 95%; TIMI Flow: 3 - Complete flow, and Post-procedure 0%
332612 - stenosis; TIMI Flow: 3 - Complete flow. ref SDS F1 QR4M
332614 - ..
332615 - Stenting 1 blocked branch vessel may be unnecessary because blockage
332616 - stimulates growth of new collateral blood vessels, and causes existing
332617 - small vessels (e.g., capillaries) to elongate, widen and form new
332618 - connections that route blood flow into the heart around the blocked
332619 - branch vessel, explained following treadmill stress test at VA Clinic
332620 - in Martinez on 091002 0900. ref SDS 5 V44I
332622 - ..
332623 - Doctor Tietjens seemed familiar with patient history hiking 11 - 20
332624 - miles per day, and noted this level of effort increases blood flow
332625 - through collateral vessels that make stenting less urgent today.
332627 - ..
332628 - After the procedure, research found...
332629 -
332630 - Harvard Health Publishing
332631 - Harvard Medical School
332633 - ..
332634 - Do-it-yourself cardiac bypass surgery: All you need is walking shoes
332635 -
332636 - Published: January, 2008
332637 -
332638 - https://www.health.harvard.edu/press_releases/do-it-yourself-cardiac-bypass-surgery
332640 - ..
332641 - When cholesterol-clogged plaque narrows an artery that feeds the
332642 - heart, the body responds by trying to bulk up tiny blood vessels
332643 - in the heart. As these so-called collateral vessels grow more
332644 - muscular and interconnected, they begin to reroute some of the
332645 - blood flow around the blockage.
332647 - ..
332648 - Exercise dramatically increases blood flow through the coronary
332649 - arteries. The inner lining of the arteries responds to this
332650 - "stress" much as it does to the stress of atherosclerosis, by
332651 - stimulating collateral blood vessels to elongate, widen, and form
332652 - new connections.
332654 - ..
332655 - ...a little bit of exercise won't do the trick. You need to push
332656 - your heart. If you aren't used to exercising, that may mean brisk
332657 - walking. Any activity that gets your heart beating faster will do
332658 - as long as you keep it up for 20 to 30 minutes at a time and do it
332659 - several times a week.
332661 - ..
332662 - Exercise is a great way to prevent heart disease, and a host of
332663 - studies show that it can help some people with narrowed coronary
332664 - arteries safely avoid bypass surgery or angioplasty.
332666 - ..
332667 - Doctor Tietjens called and left messages for Doctor Shunk and Doctor
332668 - Simpson, inviting them to come see exceptionally good results in the
332669 - procedure today.
332671 - ..
332672 - Since Doctor Shunk and Doctor Simpson did not come to the Cath Lab nor
332673 - call back, he decided to stop work, saying another procedure can be
332674 - scheduled, if needed, to stent this branch blockage.
332676 - ..
332677 - Thanked the doctor, and advised that his findings today, per above,
332678 - ref SDS 0 ME8G, are cogent and compelling for patient care.
332680 - ..
332681 - The large computer monitor screen was moved away from the left side.
332682 - Susan and Mike broke down the procedure setup removing all the
332683 - wrappings applied for the procedure.
332685 - ..
332686 - Mike wrapped the catheter access hole on the left wrist with coban
332687 - tape. He said to leave it wrapped for several days - not sure.
332689 - ..
332690 - Mike further said to avoid using left wrist for anything over 5
332691 - pounds for next few days - again not sure.
332693 - ..
332694 - Stepped down from the procedure table and laid back down on the
332695 - gurney.
332697 - ..
332698 - Was pushed back to the preparation room. Mike entered more
332699 - information into the record (progress notes) to complete the
332700 - procedure.
332702 - ..
332703 - Cynthia visited again.
332705 - ..
332706 - Mike went to get Kathy waiting in Cardiology across the hall.
332708 - ..
332709 - Cynthia was her usual bubbly self offering congratulations on such
332710 - great results. Said it will be fun working with her in the stenting
332711 - preparation study, discussed on 200122 0423. ref SDS E2 07F5 Cynthia
332712 - said I will not qualify for the stenting preparation study, because
332713 - the blockage today, was only in a branch vessel. The study is for
332714 - preparing vessel walls for stents in main arteries. Cynthia left
332715 - promising to keep in touch collaborating on future issues.
332716 -
332717 - [On 200128 0730 Cynthia visited in the hallway briefly,
332718 - while I was being pushed on a gurney into the Cath Lab for
332719 - the stent IVUS procedure, ref SDS F1 2S59; and, seemed to
332720 - say I was still eligible for PCSK9 clinical trial.
332721 - ref SDS F1 5B4K
332723 - ..
332724 - [On 200204 2252 letter to Cyn asks about joining PCSK9
332725 - study. ref SDS F4 9C9M
332727 - ..
332728 - [On 200205 1941 received letter from Cyn saying that
332729 - participation in PCSK9 study is not possible because some
332730 - protocols were not followed. ref SDS F5 9C9M
332732 - ..
332733 - Mike and Kathy returned. He had told her the good news. Kathy was
332734 - elated.
332736 - ..
332737 - Mike pushed me in a wheelchair again back to the room in Surge Med 2B
332738 - South.
332740 - ..
332741 - Thanked him for courtesy and terrific work today.
332742 -
332743 -
332745 - ..
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
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