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						"content": "Operating Room: NOT ENTERED\r\nAnesthetist: AVIVAUSER,FORTY            Relief Anesth: \r\nAnesthesiologist:                       Assist Anesth: \r\nAttending Code: \r\n\r\nAnes Begin:  SEP 26, 2012  10:00        Anes End:  SEP 26, 2012  10:10\r\n\r\nASA Class: 3-SEVERE DISTURB.\r\n\r\nOperation Disposition: WARD\r\n\r\nAnesthesia Technique(s): \r\nGENERAL\r\n  Agent: NONE ENTERED\r\n\r\nProcedure(s) Performed:\r\nPrincipal: NOSE JOB\r\n\r\nIntraoperative Blood Loss:              Urine Output: \r\nPAC(U) Admit Score:                     PAC(U) Discharge Score: \r\n\r\nPostop Anesthesia Note Date\/Time: \r\n",
						"dateTime": 201200201000,
						"status": "completed",
						"uid": "urn:va:tiu:2C0A:229:4541"
					}, {
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20120928111613,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "The Postop Anesthesia Note Date\/Time field was changed\r\n  from <NOT ENTERED>\r\n    to SEP 27, 2012@14:00\r\n\r\nThe Postop Anesthesia Note field was changed\r\n >> from original Postop Anesthesia Note text: <NO TEXT ENTERED>\r\n >> to updated Postop Anesthesia Note text:\r\n    ADDING A NOTE\r\n    FROM YESTERDAY (2)\r\n    TO THE ADDENDUM (3)\r\n    (4)\r\n\r\nThe Postoperative Disposition field was changed\r\n  from WARD\r\n    to OPERATING ROOM\r\n\r\nThe Anesthesia Technique(s) subfile was changed as follows:\r\n\r\n  The Anesthesia Technique entry GENERAL was changed:\r\n    The Principal Technique field was changed\r\n      from <NOT ENTERED>\r\n        to YES\r\n    The Monitored Anesthesia Care ? (Y\/N) field was changed\r\n      from <NOT ENTERED>\r\n        to YES\r\n    The Intubated ? (Y\/N) field was changed\r\n      from <NOT ENTERED>\r\n        to YES\r\n    The Approach field was changed\r\n      from <NOT ENTERED>\r\n        to BLIND\r\n    The Route field was changed\r\n      from <NOT ENTERED>\r\n        to ORAL\r\n    The Laryngoscope Type field was changed\r\n      from <NOT ENTERED>\r\n        to FIBEROPTIC STYLET\r\n    The Laryngoscope Size field was changed\r\n      from <NOT ENTERED>\r\n        to 1\r\n    The Stylet Used (Y\/N) field was changed\r\n      from <NOT ENTERED>\r\n        to YES\r\n    The Lidocaine Topical field was changed\r\n      from <NOT ENTERED>\r\n        to YES\r\n    The Lidocaine IV field was changed\r\n      from <NOT ENTERED>\r\n        to NO\r\n    The Tube Type field was changed\r\n      from <NOT ENTERED>\r\n        to OTHER\r\n    The Tube Size field was changed\r\n      from <NOT ENTERED>\r\n        to 2\r\n\r\nThe Monitor(s) subfile was changed as follows:\r\n\r\n  The following Monitor was ADDED:\r\n    Monitor: ECG\r\n\r\nAddendum Comment: ADDING A COMMENT TO THIS CASE ON 9\/28\/12\r\n",
						"dateTime": 20120928111613,
						"status": "COMPLETED",
						"uid": "urn:va:tiu:2C0A:229:4551"
					}],
					"uid": "urn:va:tiu:2C0A:229:4541"
				}, {
					"documentClass": "SURGICAL REPORTS",
					"documentTypeCode": "SR",
					"documentTypeName": "Surgery Report",
					"encounterName": "7A GEN MED Jul 01, 2011",
					"encounterUid": "urn:va:visit:2C0A:229:7193",
					"facilityCode": "500S",
					"facilityName": "SLC-FO HMP SQA",
					"localId": 4542,
					"localTitle": "NURSE INTRAOPERATIVE REPORT",
					"referenceDateTime": 201200201000,
					"status": "completed",
					"subject": "Case #: 10143",
					"text": [{
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20120926141051,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "Operating Room:  NOT ENTERED            Surgical Priority: NOT ENTERED\r\nPatient in Hold: NOT ENTERED            Patient in OR:  SEP 26, 2012  10:00\r\nOperation Begin: SEP 26, 2012  10:00    Operation End:  SEP 26, 2012  10:15\r\n                                        Patient Out OR: SEP 26, 2012  10:16\r\n\r\nMajor Operations Performed:\r\nPrimary: NOSE JOB\r\n\r\nWound Classification: NOT ENTERED\r\nOperation Disposition: WARD\r\nDischarged Via: N\/A\r\n\r\nSurgeon: AVIVAUSER,FORTY                First Assist: N\/A\r\nAttend Surg: AVIVAUSER,FORTY            Second Assist: N\/A\r\nAnesthetist: AVIVAUSER,FORTY            Assistant Anesth: N\/A\r\n\r\nOther Scrubbed Assistants: N\/A\r\n\r\nOR Support Personnel:\r\n  Scrubbed                              Circulating\r\n  N\/A                                   N\/A\r\n\r\nOther Persons in OR: N\/A\r\n\r\nPreop Mood:       N\/A                   Preop Consc:    N\/A\r\nPreop Skin Integ: N\/A                   Preop Converse: N\/A\r\nConfirm Correct Patient Identity: YES\r\nConfirm Procedure to be Performed: YES\r\nConfirm Site of the Procedure, including laterality: YES\r\nConfirm Valid Consent Form: YES\r\nConfirm Patient Position: YES\r\nConfirm Procedure Site has been Marked Appropriately and that the Site of the \r\n Mark is Visible After Prep and Draping: YES\r\nPertinent Medical Images have been Confirmed: YES\r\nCorrect Medical Implant(s) is available: YES\r\nAvailability of Special Equipment: YES\r\nAppropriate Antibiotic Prophylaxis: YES\r\nAppropriate Deep Vein Thrombosis Prophylaxis: YES\r\nBlood Availability: YES\r\nChecklist Comment: NO COMMENTS ENTERED\r\n\r\nChecklist Confirmed By: AVIVAUSER,FORTY\r\n\r\nSkin Prep By: N\/A                       Skin Prep Agent: N\/A\r\nSkin Prep By (2): N\/A                   2nd Skin Prep Agent: N\/A\r\n\r\nPreop Surgical Site Hair Removal by: N\/A\r\nSurgical Site Hair Removal Method: NO HAIR REMOVED\r\n  Hair Removal Comments: NO COMMENTS ENTERED\r\n\r\nSurgery Position(s): \r\n  SUPINE                                Placed: N\/A\r\n\r\nRestraints and Position Aids: \r\n  SAFETY STRAP                      Applied By: N\/A\r\n\r\nElectrocautery Unit:       N\/A\r\nESU Coagulation Range:     N\/A\r\nESU Cutting Range:         N\/A\r\nElectroground Position(s): N\/A\r\n\r\nMaterial Sent to Laboratory for Analysis: \r\nSpecimens: N\/A\r\nCultures:  N\/A\r\n\r\nAnesthesia Technique(s):\r\n  GENERAL\r\n\r\nTubes and Drains: N\/A\r\n\r\nTourniquet: N\/A\r\n\r\nThermal Unit: N\/A\r\n\r\nProsthesis Installed: N\/A\r\n\r\nMedications: N\/A\r\n\r\nIrrigation Solution(s): N\/A\r\n\r\nBlood Replacement Fluids: N\/A\r\n\r\nSponge Count Correct:     N\/A\r\nSharps Count Correct:     N\/A\r\nInstrument Count Correct: N\/A\r\nCounter:                  N\/A\r\nCounts Verified By:       N\/A\r\n\r\nDressing: N\/A\r\nPacking:  N\/A\r\n\r\nBlood Loss:                             Urine Output: \r\n\r\nPostoperative Mood:           N\/A\r\nPostoperative Consciousness:  N\/A\r\nPostoperative Skin Integrity: N\/A\r\nPostoperative Skin Color:     N\/A\r\n\r\nLaser Unit(s): N\/A\r\n\r\nSequential Compression Device: N\/A\r\n\r\nCell Saver(s): N\/A\r\n\r\nDevices: N\/A\r\n\r\nNursing Care Comments: NO COMMENTS ENTERED\r\n",
						"dateTime": 201200201000,
						"status": "completed",
						"uid": "urn:va:tiu:2C0A:229:4542"
					}, {
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20120927185258,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "The Blood Availability field was changed\r\n  from YES\r\n    to NO\r\n\r\nThe Checklist Comment field was changed\r\n >> from original Checklist Comment text: <NO TEXT ENTERED>\r\n >> to updated Checklist Comment text:\r\n    ENTERING A CHECKLIST COMMENT\r\n    LINE 2\r\n    LINE 3\r\n\r\nAddendum Comment: ADDING A COMMMENT TO THIS CASE AFTER ADDING AN ADDENDUM\r\n",
						"dateTime": 20120927185258,
						"status": "COMPLETED",
						"uid": "urn:va:tiu:2C0A:229:4549"
					}, {
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20120928111613,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "The Postoperative Disposition field was changed\r\n  from WARD\r\n    to OPERATING ROOM\r\n\r\nAddendum Comment: ADDING A COMMENT TO THIS CASE ON 9\/28\/12\r\n",
						"dateTime": 20120928111613,
						"status": "COMPLETED",
						"uid": "urn:va:tiu:2C0A:229:4550"
					}],
					"uid": "urn:va:tiu:2C0A:229:4542"
				}, {
					"documentClass": "SURGICAL REPORTS",
					"documentTypeCode": "SR",
					"documentTypeName": "Surgery Report",
					"encounterName": "7A GEN MED Jul 01, 2011",
					"encounterUid": "urn:va:visit:2C0A:229:7193",
					"facilityCode": "500S",
					"facilityName": "SLC-FO HMP SQA",
					"localId": 4543,
					"localTitle": "OPERATION REPORT",
					"referenceDateTime": 201200201000,
					"status": "completed",
					"subject": "Case #: 10143",
					"text": [{
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20120926141211,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "ENTERING A NOTEYEAH!!!\r\n",
						"dateTime": 201200201000,
						"status": "completed",
						"uid": "urn:va:tiu:2C0A:229:4543"
					}, {
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20120928154648,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "adding an addendum (1)to an operation report (2)\r\n(3)\r\n",
						"dateTime": 20120928154615,
						"status": "COMPLETED",
						"uid": "urn:va:tiu:2C0A:229:4553"
					}],
					"uid": "urn:va:tiu:2C0A:229:4543"
				}, {
					"documentClass": "PROGRESS NOTES",
					"documentTypeCode": "CR",
					"documentTypeName": "Consult Report",
					"encounterName": "7A GEN MED Jul 01, 2011",
					"encounterUid": "urn:va:visit:2C0A:229:7193",
					"facilityCode": "500S",
					"facilityName": "SLC-FO HMP SQA",
					"localId": 4548,
					"localTitle": "GENERIC CONSULT NOTE",
					"nationalTitle": {
						"title": "REFERRAL CONSULT",
						"vuid": 4695095
					},
					"nationalTitleService": {
						"service": "REFERRAL",
						"vuid": 4696247
					},
					"nationalTitleType": {
						"type": "CONSULT",
						"vuid": 4696107
					},
					"referenceDateTime": 201209271838,
					"status": "completed",
					"text": [{
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20120927183927,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "completingvia\r\ncprs\r\nand\r\ndoing\r\na\r\nword\r\na\r\nline\r\n...\r\n",
						"dateTime": 201209271838,
						"status": "completed",
						"uid": "urn:va:tiu:2C0A:229:4548"
					}, {
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20120928112230,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "MAKING AN ADDENDUM (1)TO A NOTE (2)\r\nIN CPRS(3)\r\n(4)\r\n",
						"dateTime": 20120928112155,
						"status": "COMPLETED",
						"uid": "urn:va:tiu:2C0A:229:4552"
					}],
					"uid": "urn:va:tiu:2C0A:229:4548"
				}, {
					"documentClass": "PROGRESS NOTES",
					"documentTypeCode": "D",
					"documentTypeName": "Advance Directive",
					"encounterName": "7A GEN MED Jul 01, 2011",
					"encounterUid": "urn:va:visit:2C0A:229:7193",
					"facilityCode": "500S",
					"facilityName": "SLC-FO HMP SQA",
					"localId": 4555,
					"localTitle": "ADVANCE DIRECTIVE COMPLETED",
					"nationalTitle": {
						"title": "ADVANCE DIRECTIVE",
						"vuid": 4693421
					},
					"nationalTitleType": {
						"type": "ADVANCE DIRECTIVE",
						"vuid": 4696095
					},
					"referenceDateTime": 201210011722,
					"status": "completed",
					"text": [{
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20121001172307,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "completing an advance directive2\r\n3\r\n4\r\n5\r\n6\r\n7\r\n8\r\n9\r\n10\r\nhahahahahahahahaha\r\n",
						"dateTime": 201210011722,
						"status": "completed",
						"uid": "urn:va:tiu:2C0A:229:4555"
					}],
					"uid": "urn:va:tiu:2C0A:229:4555"
				}, {
					"documentClass": "PROGRESS NOTES",
					"documentTypeCode": "A",
					"documentTypeName": "Allergy\/Adverse Reaction",
					"encounterName": "7A GEN MED Jul 01, 2011",
					"encounterUid": "urn:va:visit:2C0A:229:7193",
					"facilityCode": "500S",
					"facilityName": "SLC-FO HMP SQA",
					"localId": 4556,
					"localTitle": "Adverse React\/Allergy",
					"referenceDateTime": 201210011723,
					"status": "completed",
					"text": [{
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20121001172426,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "adding an adverse reactionhere\r\non\r\nline\r\n55555555555555555555555555555555555\r\n",
						"dateTime": 201210011723,
						"status": "completed",
						"uid": "urn:va:tiu:2C0A:229:4556"
					}, {
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20121001172505,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "adding an addendum",
						"dateTime": 20121001172432,
						"status": "COMPLETED",
						"uid": "urn:va:tiu:2C0A:229:4557"
					}],
					"uid": "urn:va:tiu:2C0A:229:4556"
				}, {
					"documentClass": "PROGRESS NOTES",
					"documentTypeCode": "W",
					"documentTypeName": "Clinical Warning",
					"encounterName": "7A GEN MED Jul 01, 2011",
					"encounterUid": "urn:va:visit:2C0A:229:7193",
					"facilityCode": "500S",
					"facilityName": "SLC-FO HMP SQA",
					"localId": 4558,
					"localTitle": "CLINICAL WARNING",
					"referenceDateTime": 201210011735,
					"status": "completed",
					"text": [{
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20121001173648,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "addinga\r\nclinical\r\nwarning\r\non\r\n10\/1\/12\r\n",
						"dateTime": 201210011735,
						"status": "completed",
						"uid": "urn:va:tiu:2C0A:229:4558"
					}, {
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20121001174013,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "addingan\r\naddendum\r\n",
						"dateTime": 20121001173955,
						"status": "COMPLETED",
						"uid": "urn:va:tiu:2C0A:229:4559"
					}],
					"uid": "urn:va:tiu:2C0A:229:4558"
				}, {
					"documentClass": "PROGRESS NOTES",
					"documentTypeCode": "C",
					"documentTypeName": "Crisis Note",
					"encounterName": "7A GEN MED Jul 01, 2011",
					"encounterUid": "urn:va:visit:2C0A:229:7193",
					"facilityCode": "500S",
					"facilityName": "SLC-FO HMP SQA",
					"localId": 4560,
					"localTitle": "CRISIS NOTE",
					"referenceDateTime": 201210011741,
					"status": "completed",
					"text": [{
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20121001174219,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "addinga\r\ncrisis\r\nnote\r\n",
						"dateTime": 201210011741,
						"status": "completed",
						"uid": "urn:va:tiu:2C0A:229:4560"
					}, {
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 201210011744,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "addingan\r\naddendum\r\n",
						"dateTime": 20121001174343,
						"status": "COMPLETED",
						"uid": "urn:va:tiu:2C0A:229:4561"
					}],
					"uid": "urn:va:tiu:2C0A:229:4560"
				}, {
					"documentClass": "DISCHARGE SUMMARY",
					"documentTypeCode": "DS",
					"documentTypeName": "Discharge Summary",
					"encounterName": "7A GEN MED Mar 25, 2004",
					"encounterUid": "urn:va:visit:2C0A:229:3309",
					"facilityCode": "500S",
					"facilityName": "SLC-FO HMP SQA",
					"localId": 4562,
					"localTitle": "Discharge Summary",
					"nationalTitle": {
						"title": "DISCHARGE SUMMARY",
						"vuid": 4693715
					},
					"nationalTitleType": {
						"type": "DISCHARGE SUMMARY",
						"vuid": 4696112
					},
					"referenceDateTime": 20040325191633,
					"status": "completed",
					"text": [{
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
						}, {
							"name": "AVIVAUSER,FORTY",
							"role": "S",
							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20121001180438,
							"uid": "urn:va:user:2C0A:1131"
						}],
						"content": "Admission Diagnosis: 1) Chest pain\r\n2) Shortness of breath\r\n \r\nDischarge Diagnosis:\r\n1) Acute coronary syndromes\r\n2) CHF exacerbation\r\n3) Hyperlipidemia\r\n4) Hypertension\r\n5) Controlled Diabetes Mellitus II:\r\n \r\n \r\nHome Outpatient Medications:\r\n1)   Metoprolol 50mg PO BID\r\n2)   Metformin HCL 500 mg PO BID\r\n3)   Simvastatin 40mg PO QPM\r\n4)   Asprin 81mg PO QDAY\r\n \r\nDischarge Medications:\r\n1)   Metoprolol 50 mg PO BID\r\n2)   Metformin HCL 500 mg PO BID\r\n3)   Simvastatin 40mg PO QPM\r\n \r\nNon VA Medications:\r\n1) Aspirin 81mg PO QDAY\r\n \r\nI had reviewed and completed medication reconciliation.\r\n \r\nTests: \r\n1) Transthoracic ECHOcardiogram\r\nImpressions\r\nMild LVH with significantly reduced LV systolic function. EF visually \r\nestimated to be 25%.\r\nSummary\r\nA). Indication: Assess left ventricular function. Assess left ventricular \r\nejection fraction.\r\nB). Left ventricle: The ventricle was mildly dilated. Systolic function \r\nwas \r\nmoderately to markedly reduced. Ejection fraction was estimated to be 25 \r\n%. \r\nThis study was inadequate for the evaluation of regional wall motion. \r\nWall \r\nthickness was mildly increased. There was mild concentric hypertrophy.\r\n \r\n2) ECG\r\nEKG showed 4 mm ST elevation in inferior leads. \r\nNew left axis deviation and inverted T-waves in V3-6 were found.\r\n \r\n3) Cardiac catherization.\r\nNo significant coronary disease noted.\r\n \r\nReason for Admission:\r\n \r\nPatient is 71yo with a history of poorly controlled DM and \r\nHTN who presented to the ED today with a 5 day history of worsening chest \r\npain and shortness of breath with associated dyspnea at rest, PND, and \r\northopnea. Patient reports that beginning 5 days ago experienced a \r\nfeeling of anxiety while laying in bed.   Patient had difficulty \r\nbreathing and chest became tight.  Patient sat up in bed and the feeling \r\neased. Since then pateint has had intermittent feelings of pressure, \r\npatient had resistance on his chest while lying down.  Patient feels like \r\nhe can't catch his breath.  Patient reports R shoulder cramping, left \r\nlower chest pain. These episodes vary in length of time, but the \r\nshortness of breath lasts all day. Patient reports thinking the symptoms \r\nare associated with his taking metoprolol. In the ED the patient sats \r\nwere 88 while lying down. Patient was given lasix and after a while the \r\nfeeling of fullness in chest dissipated. Other associated symptoms: + \r\nchest pain, duration longer than 10 minutes, + chest pressure, heavy \r\nquality + discomfort, neck or jaw or shoulder or arm. At last admission \r\nhad metoprolol for his BP control.\r\nPatient was admitted to r\/o ischemic event. \r\n \r\nHospital Course: \r\n1) Chest pain: Pateint was ruled in for an ischemic event with positive \r\nserial cardiac \r\nenzymes and noted ST elevation. Additionally, new left axis deviation and \r\ninverted T-\r\nwaves in V3-6 were found. Patient had persistent but finally resolved \r\nchest pain over his \r\nadmission. Cardiac catheterization done this admission did not reveal any \r\nsignificant coronary disease.  In 2003, pt was found to have non-ischemic \r\ndilated cardiomyopathy \r\nwith an EF of 35-40% on GXT and Echo. Pt had TTE on 3\/12\/07 showing an EF \r\nof \r\n25%. Pt SOB continued to improve with Lasix.  Sublingual nitroglycerin \r\nwas also provided to patient.\r\n \r\n2) Shortness of breath\/Non-ischemic Dilated Cardiomyopathy: Patient has \r\nknown EF of 35%. Echo done today to determine if EF is preserved and had \r\ndecreased to 25%.  CXR and symptoms consistent with CHF that improved \r\nwith diuresis.   Patient was started on \r\nLasix IV which bumped his Cr from 1.2 to 1.5. Lasix was converted to po. \r\nWeight counseling provided for CHF;  patient has a scale at home.\r\n \r\n3) Hypertension: Patient has controlled hypertension. On last admission, \r\npt was \r\nprescribed Metoprolol.  B\/P during this admission and prior to this \r\nadmission are well controlled.  Will continue patient on Metoprolol at \r\ndischarge. \r\n \r\n4) Uncontrolled DM II: Patient continues to have glucose fingersticks in \r\n150s-175s. Patient is receiving metformin to control diabetes.  Patient \r\nis compliant with performing and recording his sugars at home.  Spoke in \r\ngreat depth about the negative consequence of  persistently elevated \r\nblood glucose levels with the patient.  Patient agrees to follow diabetic \r\nmanagement instructions at home.\r\n \r\nDisposition:  Patient is being discharged to home today in good \r\ncondition.  Patient has follow-up arranged in the Cardiology clinic. \r\nPatient also has follow-up scheduled with their primary care provider. \r\n",
						"dateTime": 20040325191633,
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							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20121001180539,
							"uid": "urn:va:user:2C0A:1131"
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						"content": "addingan addendum\r\n",
						"dateTime": 20040325191633,
						"status": "COMPLETED",
						"uid": "urn:va:tiu:2C0A:229:4563"
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					"localTitle": "PROCEDURE REPORT",
					"referenceDateTime": 201210011000,
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					"subject": "Case #: 10145",
					"text": [{
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						"content": "ADDINGA\r\nPROCEDURE\r\nREPORT\r\n",
						"dateTime": 201210011000,
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						"content": "addinga\r\nnote\r\nfor\r\nresults\r\nof\r\na\r\nprocedure\r\n",
						"dateTime": 201210011907,
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						"content": "adding an addendum",
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					"documentClass": "LR LABORATORY REPORTS",
					"documentTypeCode": "LR",
					"documentTypeName": "Laboratory Report",
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					"localId": 4567,
					"localTitle": "LR SURGICAL PATHOLOGY REPORT",
					"referenceDateTime": 20121001000003,
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					"text": [{
						"clinicians": [{
							"name": "AVIVAUSER,FORTY",
							"role": "A",
							"uid": "urn:va:user:2C0A:1131"
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							"signature": "FORTY AVIVAUSER",
							"signedDateTime": 20121001000003,
							"uid": "urn:va:user:2C0A:1131"
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						"content": "$APHDR\r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\n     MEDICAL RECORD |                   SURGICAL PATHOLOGY\r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\n                              PATHOLOGY REPORT\r\nLaboratory: CAMP MASTER                              Accession No. SP12 SP 12 5\r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\n$TEXT\r\nSubmitted by: ONE VEHU                      Date obtained: Oct 01, 2012 19:18\r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\nSpecimen (Received Oct 01, 2012 19:18):\r\nSKIN\r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\nBRIEF CLINICAL HISTORY:\r\n     TEST \r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\nPREOPERATIVE DIAGNOSIS:\r\n     BIG NOSE \r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\nOPERATIVE FINDINGS:\r\n     TEST \r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\nPOSTOPERATIVE DIAGNOSIS:\r\n     BIG NOSE \r\n\r\n                           Surgeon\/physician: FORTY AVIVAUSER\r\n=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=\r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\n                              PATHOLOGY REPORT\r\nLaboratory: CAMP MASTER                              Accession No. SP12 SP 12 5\r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\n                               Pathology Resident: FORTY AVIVAUSER\r\n\r\nFROZEN SECTION REPORT:\r\n     TEST \r\n\r\nGROSS DESCRIPTION:\r\n     TEST \r\n\r\n\/es\/ FORTY AVIVAUSER\r\n\r\nSigned OCT 01, 2012@19:22:13\r\n$FTR\r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\n                                                         (End of report)\r\nFORTY AVIVAUSER                                     hc | Date Oct 01, 2012\r\n- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -\r\nAVIVAPATIENT,TWENTYFOUR                           STANDARD FORM 515\r\nID:666-00-0004  SEX:M DOB:04\/07\/1935  AGE: 77 LOC:7A GM\r\nADM:JUL 1,2011   DX:CHF                       PCP: ONE VEHU\r\n",
						"dateTime": 20121001000003,
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		}]
	}
}
