Re: Dr notes from my last and new PCP visit

January 25, 2012

How Do I get the two Dr to see that PA isn't all that " very rare " ?

>

> As I posted before about this visit this PCP has no clue about PA. You will

also note LVH Doesn't seem to be a concern for him. Has no relationship to

shortness of breath.

>

> LOCAL TITLE: Primary Care Clinic

> STANDARD TITLE: PRIMARY CARE NOTE

> DATE OF NOTE: OCT 27, 2011@13:34

> AUTHOR: TAYLOR,DEAN J

> URGENCY:

>

> Note

> ENTRY DATE: OCT 27, 2011@13:35

> EXP COSIGNER: GROSSMAN,ALEXANDRA

> STATUS: COMPLETED

>

> Printed at WHITE RIVER JCT VAMROC

> *** Primary Care Clinic Note Has ADDENDA ***

> Chief Complaint: 1.) Chronic shortness of breath 2.) " Brain fog "

> HPI:

> This is a morbidly obese (BMI 45) 64 yo male with pmhx notable for HTN, OSA

and

> BPV presenting with dyspnea on exertion that has been ongoing for 6 weeks and

> prompted a visit to the ED on 9/24/11. In the ED he was worked up with

negative

> CE's, negative CXR and EKG notable only for LVH. He has had intermittent

> episodes of DOE for the past 6 years and has had an extensive cardiac work-up

> including ETT X 3 most recently 2/2011 that was notable only for decreased

> functional capacity (58% of expected). He states that his DOE has not improved

> much since he was seen in the ED and that he gets sob with walking short

> distances. Prior to this most recent episode of DOE he developed vertigo type

> symptoms that lasted for a week but have since resolved. He denies any cp,

> palpitations, PND, orthopnea or sob at rest. He states that " breathing into a

> paper bag " does help his sob and he feels that he has " Conns syndrome " . I

> explained that hyperaldosteronism is very rare and that he would have low

> pottasium and a higher blood pressure if he had Conns.

> He is also c/o chronic fatigue, lightheadedness and " brain fog " that also

> started about 6 years ago. He endorses compliance with his BiPap. He has

> gained 28 pounds in the last 6 years. He exercises very little 2/2 decreased

> tolerance.

> ROS:

> Cons- Denies fevers, chills or unintentional weight loss

> Skin- Denies any new rashes, sores or ulcers

>

> PATIENT NAME AND ADDRESS (Mechanical imprinting, if available) VISTA

Electronic Medical Documentation

> BILL, FRANCIS HENRY

>

> HEENT- Denies any vision changes, ringing in ears or sore throat

> CV- Denies any chest pain or palpitations

> Resp- + for SOB as above

> GI- Denies any abdominal pain, changes in bowel habits or blood in stool

> GU- Denies any dysuria or obstructive symptoms

> MSK- Denies any arthralgias or myalgias

> Hem- Denies any easy bruising or bleeding

> Endo- Denies any cold or heat intolerance

> Neuro- Denies any weakness, numbness or tingling

> Pmhx:

> # Morbid obesity

> - BMI of 45

> # Hypertension

> # DOE

> - ETT- 4/10/2009: Negative for ischemia, Functional capacity 58% of expected

> - ECHO- 5/19/2008: EF of 55-60%, No obvious WMA

> - PFT's 11/2005: Normal spirometry

> # Dizziness and tachycardia

> - see neuro consultation 5/16/06

> - 6/06 CT= frontal atrophy of brain

> - 9/05 ETT- 6 mets, negative

> 10/05 holter- rare PACSi freq islated PVCSi underlying rhythm sinus averaging

> 71

> - 11/05 PFTs- normal spirometry

> - 11/05 carotid studies- minimal stenosis

> -11/05 loop monitor- sypmtoms sometimes with sinus tach, someties with NSR

> - 12/05 echocardiogram normal

> - 12/08 MRI of brain- mild to moderate cerebral atrophy.

> # Chronic fatigue

> # Hearing loss/tinnitus

> # RLL lung nodule

> - CT of chest 12/06= 7 mm RLL nodule

> - followup CT 5/08= stable

> # L adrenal adenoma

> - CT of chest 12/06- L adrenal nodule, likely adenoma

> - 8/7/06 VMA normal

> - 2/23/06 serum cortisol (random) normal

> - 11/09- stable appearance

> # Sleep apnea, on CPAP

> - Sleep study- 3/21/2007 -> probable sleep apnea

> # Hepatic cysts

> # Stable hyperdense cyst L kidney on 11/09 CT

> # sip laparoscopic appendectomy 12/14/D8

> Meds:

> Active Outpatient Medications (excluding Supplies) :

>

> Active Outpatient Medications

>

> 1) FUROSEMIDE 20MG TAB TAKE THREE TABLETS BY MOUTH EVERY ACTIVE

> DAY TO REMOVE FLUID/CONTROL BLOOD PRESSURE

> 2) POTASSIUM CHLORIDE 10MEQ SA TAB TAKE TWO TABLETS BY ACTIVE

> MOUTH EVERY DAY TO SUPPLEMENT POTASSIUM

>

> Active Non-VA Medications

> Non-VA ASPIRIN 325MG TAB 325MG MOUTH EVERY DAY

> Non-VA FISH OIL CAP/TAB 2 EVERY DAY

> Non-VA MULTIVITAMIN/MINERALS TAB 1 MOUTH EVERY DAY

>

> 5 Total Medications

> Allergies:

> DILTIAZEM

> Symptoms: DIZZINESS

>

> (historical)

>

> Sochx:

> Pt lives by himself in Enfield. He worked at Hitchcock hospital in the

> boiler-room for 15 years and later worked as a gardener and handyman. He is

now

> on disability. He denies any tobacco or ETOH use. He exercises very rarely and

> states that he eats sensibly but does occasionally eat junk food.

>

> Vitals:

> DATE/TIME

> 10/27/11 @ 1323

> 95% on RA

>

> TEMP

> 99.4

>

> PULSE

> 80

>

> RESP

>

> BP

> 142/73

>

> PAIN

> o

>

> WEIGHT

> 308

>

> Physical exam:

> Gen: Obese male in NAD

> Skin: No rashes, sores or ulcers

> HEENT: EOMI, PERRL, poor dentition, op clear with mmm

> Neck: Supple with normal ROM, JVD not appreciated

> CV: RRR without murmur

> Pulm: CTAB without wheezes, rales or rhonchi. SOB with getting up to the exam

> table.

> Abd: Obese, S/NT/ND, NABS, No HSM

> Ext: 1+ and equal DPP BL, 1+ pretibial pitting edema bl

> Neuro: Non-focal, moving all 4 extremities equally

> Labs:

>

> CBC:

> WBC: 7.4 (09/24/11 15:15)

>

> HCT: 44.0 (09/24/1115:15)

> HGB: 14.9 (09/24/11 15:15)

> PT : 12.2 (09/24/11 15: 15)

>

> BMP:

> GLU,BUN,CREAT,LYTES GLUCOSE BUN CREAT SODIUM K CHLOR CO2

> 9/24/11 15: 15 131 H 11 0.91 140 3.9 107 23

> GLU, BUN,CREAT,LYTES ANION eGFR

> 9/24/11 15: 15 10 84

> A/P:

> This is a 64 yo morbidly obese male with HTN, OSA, and chronic DOE with

> extensive negative cardiac workup. I had a frank discussion with the pt

> regarding his obesity and how it is contributing to his decreased functional

> status and the likely cause of most of his symptoms. Pt seems a bit unwilling

> to accept this and thinks that his symptoms might be 2/2 hyperaldosterinism

and

> mentioned talking to a specialist here at the VA. I assured him that it was

> very unlikely that he had hyperaldo and described to him why. He may benefit

> from talking to a health psychologist and was introduced to Glenna. In regards

> to his HTN, we did discontinue his atenolol as it may be worsening his

fatigue.

> He was started on lisinopril and scheduled for a BP clinic appt in 2 weeks.

>

> # DOE 2/2 deconditioning/obesity

> - Encouraged pt to exercise daily as tolerated

> # HTN

> - Stop Atenolol

> - Start lisinopril 5 mg qd

> - F/u at BP clinic in 2 weeks with lytes drawn

> # LE edema

> - Continue lasix 60 mg QD

> - Continue triamterene 50 mg QD

> #Preventative

> - Flu shot today

> Colonoscopy ordered

> HIV ordered

> Lipid panel ordered

> Hgb A1C ordered

> RTC in 4 months

> Patient seen and discussed with Dr. Grosssman who agrees with plan of care

> Dean , PGY-1

> BP>=140/90 or BP>=130/80 + DM:

> Repeat BP: 136/75

>

> The patient's medication regimen was adjusted to improve BP control.

> The patient was counseled on the importance of regular exercise

> and/or physical activity in the control of blood pressure.

> The patient was instructed to try to exercise at least 30 minutes

> 3 times per week if possible and that any increase in physical

> activity may be useful in controlling BP.

> The patient has a limited ability to exercise but was encouraged

> to increase physical activity as much as possible since any

> increase in activity may be beneficial in improving BP control.

> The patient was counseled on the importance of diet and weight

> control in the control of blood pressure.

> Co1orectal Cancer Screening:

> Patient is scheduled for a colonoscopy.

> HIV Screening

> Patient has given verbal consent for HIV antibody testing, and written

> educational materials have been provided. An order for an HIV Antibody

> test has been entered - see orders tab.

> Home Telehealth (CCHT) Referral:

> Patient declines participation in CCHT Program at this time.

> Lipid Screening(M):

> Lipid profile ordered.

> /es/ DEAN J TAYLOR

> Resident MD

> Signed: 10/27/2011 17:17

> /es/ ALEXANDRA GROSSMAN

> Staff MD

> Cosigned: 10/30/2011 20:22

> Receipt Acknowledged By:

> 12/02/2011 16:13 /es/ GLENNA S ROUSSEAU

> Clinical Psychologist

> 10/30/2011 ADDENDUM STATUS: COMPLETED

> I discussed this patient with Dr. and agree with his assessment and

plan.

> /es/ ALEXANDRA GROSSMAN

> Staff MD

> Signed: 10/30/2011 20:22

> LOCAL TITLE: Telephone Note-Primary Care

> STANDARD TITLE: PRIMARY CARE TELEPHONE ENCOUNTER NOTE

> DATE OF NOTE: SEP 26, 2011@09:14 ENTRY DATE: SEP 26, 2011@09:14:07

> AUTHOR: DATTILIO, LINDA EXP COSIGNER:

>

> Letter about labs

>

> Your hemoglobin A1C is a measure of your long-term blood sugar control. Your

> A1C was 5.7, indicating pretty good blood sugar management.

> Your cholesterol levels were very good:

>

> CHOL: 200

> HDL: 43

> LDL: 128

> TRIG: 145

>

> HDL is the good cholesterol and should be greater than 40 which yours is.

> Triglycerides are a type of bad cholesterol and should be less than 150 which

> yours is.

> LDL is the bad cholesterol and should be less than 130 which yours is.

> Don't forget that you have a blood pressure check on November 10th. You should

> get your blood drawn prior to that appointment. I hope changing your blood

> pressure medication improves your energy.

> Wishing you the best of health,

> Dean , DO

> VA Medical Center, White River Junction, VT

> /es/ DEAN J TAYLOR

> Resident MD

> Signed: 10/31/2011 13:58

> /es/ ALEXANDRA GROSSMAN

> Staff MD

> Cosigned: 11/03/2011 16:14

>

> 64 M NH vet with HTN Possable since 1966 but most B/P at that time were normal

a few with top 140, K went to 3.2 with HCTZ (2007). Sx of CHF. CT 2 cm L adrenal

adenoma(2006). Aldo Renin not classic for PA but done on meds. Never tried on

spiro or eplere but trying to get VA to try. B/P is arould 140/80 on diuretics

eating less NA not at DASH goal. Normal Echo and stress tests.

>

January 25, 2012