CONTACTS
SUBJECTS
Treadmill Heart Stress Test Schedule 200103 0700 Chest Pain Elevated
2403 -
2403 - ..
2404 - Summary/Objective
2405 -
240501 - Follow up ref SDS F7 0000. ref SDS F6 0000.
240502 -
240503 -
240504 -
240505 -
240506 -
240508 - ..
2406 -
2407 -
2408 - Background
2409 -
240901 - On 191206 1425 letter to VAMCSF Cardiology Doctor Simpson, ref SDS B4
240902 - NE9N, notify possible afib symptoms. ref SDS B4 N874
240904 - ..
240905 - On 191207 0927 Doctor Simpson to order ECG [...electrocariogram...]
240906 - Zio test for AFib, after he returns to work following several weeks
240907 - out of the office. ref SDS B5 NE9N
240909 - ..
240910 - On 191213 0849 call from Tina - scheduled install Zio equipment for
240911 - heart monitoring test; meeting room 2A16 on 191216 1230. ref SDS B6
240912 - NE9N
240914 - ..
240915 - On 191216 1220 Exmeralda in Cardiology at VAMCSF installed Zio XT
240916 - heart monitor on left chest; she added 2 plastic tapes to secure the
240917 - unit against fall off in shower and perspiration during hiking.
240918 - ref SDS C0 AO7H
240920 - ..
240921 - On 191214 1138 letter to Doctor Simpson in Cardiology at VAMCSF,
240922 - ref SDS B8 NE9N, reports 8 weeks ago increased hiking route with steep
240923 - hills from 11 to 15 miles per day. ref SDS B8 MX58 About a week ago
240924 - increased hiking to 20+ miles per day in order to improve weight
240925 - control and to raise lipids toward HDL 80. ref SDS B8 MX61 Weight
240926 - increased after pausing hiking due to orthopedic pain left knee and
240927 - both feet, which was solved after receiving oxycodone and gabapentin,
240928 - and applying elastic bandage to left knee. ref SDS B8 MX64 Today,
240929 - before hiking felt chest swaying indicating afib. ref SDS B8 MY30
240930 - Research indicates walking can aid recovery from afib; during hike
240931 - today, will reduce level of effort back to 15 miles per day, and avoid
240932 - steeper hills. ref SDS B8 368M Ask about medication to treat afib.
240933 - ref SDS B8 MY38 Offer to walk with Doctor Simpson to assist recovery
240934 - from hip surgery. ref SDS B8 MY41
240936 - ..
240937 - On 191214 1138 at 1324 letter from Doctor Simpson in Cardiology at
240938 - VAMCSF says to do hiking that has led to symptoms. ref SDS B9 0K4L
240940 - ..
240941 - On 191228 1416 letter to Doctor Simpson notify Zio log reports chest
240942 - pain hiking with elastic bandage on left knee. ref SDS C2 NE9N 1st
240943 - episode hiking 12 miles through Golden Gate Park on 191220, chest pain
240944 - mild lasted on ly .25 miles. Occurred again next day hiking 20 miles
240945 - up Crystal Ranch Road. ref SDS C2 B652 Occurred next day on 191222, so
240946 - stopped at mile .75 and removed elastic bandage from left leg, pain
240947 - ended for rest of 20 mile hike and on subsequent hikes 20 mile past 6
240948 - days. ref SDS C2 B655 Today on 191228, chest pain occurred hiking up
240949 - mild hills without elastic bandage on left leg, so ended hike at 7
240950 - miles. ref SDS C2 B658 HR 150 - should be 45 - 55. ref SDS C2 B662
240951 - Seems like bypass saphenous graft failed under elevated load wearing
240952 - elastic bandage on left knee. ref SDS C2 B665 Pause hiking until hear
240953 - from the doctor. ref SDS C2 B668
240955 - ..
240956 - On 191228 1416 at 1534 letter from Doctor Simpson notifies he will
240957 - order treadmill stress test. ref SDS C2 RK6L
240959 - ..
240960 - On 191228 1416 at 1537 letter to Doctor Simpson notifies will submit
240961 - Zio XT device with afib data on Monday, 191230. ref SDS C2 WO6F
240963 - ..
240964 - On 191229 1243 received letter from Doctor Simpson notifies need to
240965 - get ECG test at VAMCSF before they can schedule treadmill stress test.
240966 - ref SDS C4 NE9N Further says to get care in the ER if chest pain
240967 - recurs at rest. ref SDS C4 NH77
240969 - ..
240970 - On 191229 1243 at 1256 letter to Doctor Simpson asks where and when to
240971 - get ECG test. ref SDS C4 YH8N Notifies so far chest pain has not
240972 - occurred at rest; has only occurred when hiking. ref SDS C4 YA48
240973 - Notifies of EGD procedure in GI Clinic at VAMC Sacramento on 200107,
240974 - and getting MRI studies on feet and knees at VAMCSF on 200109.
240975 - ref SDS C4 YA51
240977 - ..
240978 - On 191229 1243 at 1420 received letter from Doctor Simpson advising
240979 - ECG is done on 2nd floor building 203, and to arrive about 1000.
240980 - ref SDS C4 LG4J Recommends notifying GI Clinic to delay EGD until
240981 - after resolution of current Cardiology issue. ref SDS C4 6H6G
240983 - ..
240984 - On 191229 1243 at 1538 received letter from Doctor Simpson advising
240985 - ECG was done in this case at the end of Oct, so do not need a new one;
240986 - next step is for VA to schedule stress test. ref SDS C4 E17N
240988 - ..
240989 - On 191229 1243 at 1619 sent letter to Jessica on notifying Doctor Lee
240990 - to delay next EGD scheduled on 200107 0730 for a month until 200204
240991 - 0730. ref SDS C4 4R7J
240993 - ..
240994 - On 191229 1243 at 1700 letter thanks Doctor Simpson for advising ECG
240995 - not needed. ref SDS C4 M48J
240997 - ..
240998 - On 191229 1243 at 1946 letter notifies Doctor Simpson that feet
240999 - elevated on footrest seem swelled. Cellphone reports HR 38. That is
241000 - low for me. Don't feel dizzy or light headed; seems like afib event,
241001 - with chest swaying back and forth. ref SDS C4 MH6N
241003 - ..
241004 - On 191229 1243 at 1946 letter notifies Doctor Simpson Zio device was
241005 - mailed to company a day early on 191229. ref SDS C4 UA47
241007 - ..
241008 - On 191230 0930 received call from Tina in Cardiology at VAMCSF
241009 - scheduled treadmill stress test on 200103, ref SDS C6 NE9N, report
241010 - first at 0700 to ASU on 3rd floor Building 200 for IV, then go to
241011 - Neuclear Medicine on ground floor building 203. ref SDS C6 GE5K
241013 - ..
241014 - On 191230 0930 at 0938 received letter from Doctor Simpson in
241015 - Cardiology explaining symptoms reported last night are okay, since not
241016 - dizzy, until after stress test. ref SDS C6 GF3G
241018 - ..
241019 - On 191230 0930 at 0949 received letter Tina in Cardiology confirming
241020 - schedule for stress test on 200103 0700, and submitting instructions
241021 - to prepare for the test. ref SDS C6 Q76I
241023 - ..
241024 - On 191230 0930 at 1021 letter to Doctor Simpson in Cardiology at
241025 - VAMCSF reporting stress test has been scheduled on 200301 0700.
241026 - ref SDS C6 9W6F Reported mild chest pain at rest for 10 minutes, but
241027 - it resolved while writing the letter. ref SDS C6 JY39
241029 - ..
241030 - On 191230 0930 at 1114 received letter from Lauren, NP and PCP in this
241031 - case; she concurs patient should go to ER if chest pain persists at
241032 - rest, and should have a driver. ref SDS C6 2S4N
241034 - ..
241035 - On 191230 0930 at 1117 received call from Aladin who is Lauren's
241036 - assistent in Medical Practice; he indicated Lauren asked him to call
241037 - and get background on chest pain issue. ref SDS C6 578G Explained
241038 - background is reported in correspondence with Doctor Simpson in
241039 - Cardiology, and this has been copied to Lauren. ref SDS C6 5W6J
241041 - ..
241042 - On 191230 0930 at 1135 responded to Lauren citing call from her
241043 - assistent, Aladin, and reporting background on current issue is
241044 - reported in correspondence with Doctor Simpson in Cardiology, who is
241045 - directing the work, and that Lauren has been copied on all
241046 - correspondence. ref SDS C6 659K
241048 - ..
241049 - On 200108 1130 Doctor Simspon ordered cardiac catheterization
241050 - (Angiogram) to evaluate for failed saphenous bypass graph. ref SDS D3
241051 - UV3M He also cordered Echocardiogram (ECHO) to evaluate cardiac
241052 - remodeling that may be causing atrial fibrillation. ref SDS D3 GG4F
241054 - ..
241055 - On 200113 0841 call from Gina in Cardiology scheduled echocardiogram
241056 - on 200214 1300 to evaluate for cardiac remodeling causing AF due to
241057 - high-intensity hiking. ref SDS D7 NE9N
241059 - ..
241060 - On 200115 0933 called VA Cardiology, ref SDS D9 Q18G; and talked to
241061 - Sue, who has taken the position of Karen for scheduling and
241062 - coordinatoing patient procedures. ref SDS D9 NB9G Sue scheduled
241063 - cardiac catheterization (angiography) on 200128 0730; and, pause
241064 - Apixaban blood thinner 2 days before the procedure. ref SDS D9 4L5N
241066 - ..
241067 - On 200115 0933 at 1747 submitted letter confirming work plan for
241068 - cardiac catheterization on 200128. ref SDS D9 5J7M
241070 - ..
241071 - On 200115 0933 at 1936 submitted another letter correcting date error
241072 - in the letter at 1747. ref SDS D9 4K5G
241074 - ..
241075 - On 200116 0948 received letter from Sue in Cardiology at VAMCSF
241076 - instructions for cardiac catheterization scheduled 200118, ref SDS E0
241077 - G367, pause Apixaban 2 days before 200118, ref SDS E0 G45M; NPO after
241078 - midnight, and until after Cath, ref SDS E0 6S30; bring list of
241079 - medications, ref SDS E0 6S76; bring charger for cellphone, ref SDS E0
241080 - 4B9H; do not drive for 24 hours after cardiac catheterization.
241081 - ref SDS E0 6S98
241083 - ..
241084 - On 200124 0705 cardiac catheterization angiogram performed by Doctor
241085 - Tietjens, ref SDS F1 V544; found all 4 bypass grafts completely clear -
241086 - no plaque buildup of any amount. Saphenous vein grafts in very good
241087 - condition 10 years after CABG x4; best result he has ever seen. He
241088 - said to continue doing whatever you are doing to achieve this
241089 - exceptional result. ref SDS F1 ME8G Doctor asked about hiking and HDL?
241090 - Hiking 3 - 8 miles per day 4 - 6 times a week yielded HDL 30 at time
241091 - of CABG x4 on 091022. About 4 years after surger, increased hiking to
241092 - 11 - 20 miles per day up to 7 days a week, this raised cholesterol to
241093 - HDL 83, that regressed plaque in blood vessels. ref SDS F1 CN7I
241095 - ..
241096 - On 200127 090153 Caroline called scheduled meeting with Doctor
241097 - Pelligrini in Cardiology Arrhythmia Clinic to schedule procedure
241098 - pulmonary vein isolation ablation resolve chest pain peroxysmal atrial
241099 - fibrillation (PAF). ref SDS F3 9C9M
241101 - ..
241102 - On 200320 1741 call from Doctor Pelligrini reporting 2nd Zio heart
241103 - monitor test found PAF episodes increased from 15% found in the 1st
241104 - Zio test last December to 23%. ref SDS 0 9C9M Progression of disease
241105 - requires ablation medical procedure to restore regular sinus heart
241106 - beat, which must be deferred 3 - 4 weeks during current coronavirus
241107 - pandemic. ref SDS 0 YV4L
241108 -
241109 -
241111 - ..
2412 -
2413 -
2414 - Progress
2415 -
241501 - Doctor Pellegrini called responding to the letter submitted on 200316,
241502 - and another next day on 200317, reporting shortness of breath. This
241503 - call follows up meeting with the doctor in her office at VAMCSF on
241504 - 200219 1150. ref SDS F7 9C9M
241506 - ..
241507 - The doctor said the 2nd Zio XT test completed on 200304 1344,
241508 - ref SDS F8 9C9M (and submitted on 200306 1030, ref SDS F9 9C9M), shows
241509 - PAF 23% of the time, which is a 50% increase from 15% found in the
241510 - initial test, reported on 191229 1517. ref SDS C5 I69J This
241511 - demonstrates PAF has worsened.
241513 - ..
241514 - She feels PAF progression requires doing ablation. The procedure must
241515 - be deferred perhaps 4 - 6 weeks due to emergency coronavirus
241516 - re-direction of hospital resources.
241518 - ..
241519 - The doctor advised that VAMCSF currently has 1 or 2 patients being
241520 - treated for coronavirus. An influx of patients with coronavirus is
241521 - expected over the coming weeks.
241523 - ..
241524 - Advised PAF in this case may have increased, since ending the 2nd Zio
241525 - test on 200304 1344. ref SDS F8 9C9M After being in PAF the entire
241526 - hike on 200319 (see case study on 200101 0702, ref SDS C8 RTTV), and
241527 - afterward into the night, am relieved have been in sinus skipping the
241528 - hike today.
241530 - ..
241531 - Reviewed "shortness of breath" issue, and liklihood this represents
241532 - fluid in the lungs caused by PAF, explained in research reported on
241533 - 200219 1150, ref SDS F7 W344, and recently presented in a letter to
241534 - Doctor Pellegrini on 200317. Read some of the research for the
241535 - doctor...
241536 -
241537 - AFib can lead to heart failure because the heart is beating so
241538 - fast that it never properly fills up with blood to pump out to
241539 - the body.
241541 - ..
241542 - Blood can "back up" in the pulmonary veins (the vessels that
241543 - return oxygen-rich blood from the lungs to the heart.) which
241544 - can cause fluid to back up into the lungs.
241546 - ..
241547 - When AFib causes heart failure, fluid in the lungs can cause
241548 - fatigue and shortness of breath. Oxygen-rich blood is not being
241549 - delivered to the body and brain, causing physical and mental
241550 - fatigue and reduced stamina.
241552 - ..
241553 - The doctor seemed to say the Zio XT results show the heart in this
241554 - case is squeezing blood very well out of the chambers. Therefore,
241555 - very little blood should backup. Of course severity of PAF could have
241556 - worsened, since the 2nd Zio test ended 2 weeks ago on 200304, in the
241557 - same way that PAF increased from 15% to 23% since prior Zio ended on
241558 - 191229.
241560 - ..
241561 - Doctor Pellegrini asked how "shortness of breath" feels?
241563 - ..
241564 - Explained struggling to breath in air, because not enough is coming
241565 - into the lungs. Hiking on flat surfaces or going up moderate hills
241566 - breathing through nose is easy. As steepness increases, for example
241567 - on Crystal Ranch Road, the past 3 years, breathing is easy through my
241568 - nose all the way to the summit. Since onset of PAF in December, past
241569 - halfway up, the feeling of not getting enough air gets worse, until
241570 - finally have to switch to beathing through the mouth. Last time I
241571 - hiked Crystal Ranch Road even breathing through the mouth became
241572 - difficult to get to the summit, reported 4-days ago on 200316 (in case
241573 - study on 200101 0702, ref SDS C8 QVWV, see line 092533, say in part...
241575 - ..
241576 - Hiked up to the end of Crystal Ranch Road very steep hill .5
241577 - mile to top of the mountain. Another difficult struggle, HR
241578 - 122 - breathing through nose halfway - HR 148; swithched to
241579 - breating through mouth - HR fell to 123; but increased rest
241580 - of way to top - HR 151. Had shortness of breath today, even
241581 - breathing through mouth. At summit HR dropped to 123.
241583 - ..
241584 - Shortness of breath hiking up hills is not constant. There are days,
241585 - when it is easy to hike breathing through the nose all the way to the
241586 - top. Thus, the problem comes and goes.
241588 - ..
241589 - Fluid in the lungs seems a reasonable explanation, as something that
241590 - enables normal breathing to a point, then prevents full breathing as
241591 - demand increases hiking up steep hills, but lungs cannot fully expand.
241592 - Later during a period of extended sinus, fluid might simply drain
241593 - away. Then hiking up steep hills is easy breathing through the nose
241594 - all the way to the summit, because lungs can fully expand without
241595 - fluid obstruction. Hiking stimulates PAF, which then generates fluid
241596 - again in the lungs, per research above, ref SDS 0 435G, which then
241597 - causes "shortness of breath" hiking the next steep hill - something
241598 - like that...
241600 - ..
241601 - Reviewed breathing impairment bending down to ties shoes, doing
241602 - windmill calisthenics, getting a box of Cheerios from a cupboard shelf
241603 - near the floor, etc., presents similarly to hiking up steep hills.
241604 - The head feels heavy or congested, but there is no actual congestion.
241605 - Just feels like you are not getting any air, until you stand vertical.
241606 - Even laying down flat on your back in bed causes shortness of breath.
241607 - It is as if fluid in the lungs flows with lowering of the head.
241608 - Sometimes turning the body toward the left side, causes the fluid to
241609 - drain away. There is no sense of fluid draining, but there is a
241610 - feeling shortness of breath reduces and ends.
241612 - ..
241613 - Doctor Pellegrini indicated other PAF patients have described similar
241614 - sensations for "shortness of breath".
241616 - ..
241617 - Explained before onset of PAF in December, normal HR going up
241618 - difficult hills in sinus is below 120. It is very hard to get HR
241619 - above 130 by running uphill. The past few months HR reaches 160 going
241620 - up steep hills, shown in Palor Vantage V HR diagnostics, submitted
241621 - with the letter to the team on 200309.
241623 - ..
241624 - Pending ablation to resolve PAF, Doctor Pellegrini proposes further
241625 - medication to reduce elevated HR during hikes, so that PAF does not
241626 - worsen into permanent AF.
241628 - ..
241629 - She feels lowering HR with additional medication may reduce shortness
241630 - of breath episodes. She does not want to increase metoprolol, because
241631 - current dose is causing adverse side effects of fatigue/sleepiness and
241632 - diminished vision, reported in the letter on 200306.
241634 - ..
241635 - Another concern is lowering HR below 30. There have been several
241636 - times, when HR has fallen into the high 20s, but even in the 30s may
241637 - not be a good situation. What does Zio XT report show on low HR?
241639 - ..
241640 - Maybe additional medication to lower HR can be limited to before
241641 - hiking, which seems to trigger PAF.
241643 - ..
241644 - Doctor Pellegrini will order Amiodarone. This was taken after CABG x4
241645 - surgery, reported on 091104 0718. ref SDS 9 4193 It was ended a month
241646 - later on 091122, planned in the meeting with the medical team on
241647 - 091119 1000. ref SDS 10 LC5F Today, the doctor advised Amiodarone
241648 - will supplement metoprolol, rather than replace it.
241650 - ..
241651 - The patient has a history of sensitivity to drug side effects, e.g.,
241652 - acetaminophen, omeprazole, pantoprazole, versed.
241654 - ..
241655 - Will try amiodarone for a month. The doctor checked the record and
241656 - found most recent labs show thyroid levels align with requirements for
241657 - taking amiodraone. She will order futher labs to verify adverse side
241658 - effects do not occur.
241660 - ..
241661 - Critical exercise requirement is preventing paroxysmal AF from
241662 - worsening to become persistent AF. Generally, people with paroxysmal
241663 - atrial fibrillation caused by high-intensity, endurance exercise that
241664 - increases conditioning, shown by low HR, i.e., bradycardia, can
241665 - sometimes recover by de-conditioning, cited in research on 200103
241666 - 0700. ref SDS C9 XD5O
241668 - ..
241669 - The doctor feels hiking must continue for treating PAF, and notes a U
241670 - curve requires avoiding too much, i.e., finding the "sweet spot"
241671 - between too little and too much, as set out in correspondence with
241672 - Doctor Simpson on 191214 1138. ref SDS B7 MX67
241674 - ..
241675 - Thanked Doctor Pellegrini for good care.
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