MHV COBIN 20161101 1148 PDF

CONFIDENTIAL

COBIN, FRED

Page 1 of 57

My HealtheVet
Personal Information Report

*************CONFIDENTIAL*************
Produced by the VA Blue Button (v12.10)
01 Nov 2016 @ 1148
This summary is a copy of information from your My HealtheVet Personal Health Record. Your
summary may include:
information that you entered (self reported)
information from your VA health record
your military service information from the department of defense (DoD)
***Note: Your health care team may not have all of the information from your Personal Health Record
unless you share it with them. Contact your health care team if you have questions about your health
information.***
Key: Double dashes (--) mean there is no information to display.
Name: COBIN, FRED
Date of Birth: 06 Aug 1947
COBIN, FRED
CONFIDENTIAL
Download Request Summary

System Request Date/Time:
File Name:
Date Range Selected:
Data Types Selected:
01 Nov 2016 @ 1148

mhv_COBIN_20161101_1148.pdf
01 Nov 2015 to 01 Nov 2016
My HealtheVet Account Summary
VA Wellness Reminders
VA Problem List
VA Admissions and Discharges
VA Notes
DoD Military Service Information
Page 2 of 57
CONFIDENTIAL
COBIN, FRED
Page 3 of 57
My HealtheVet Account Summary

Source:
Authentication Status:
Authentication Date:
Authentication Facility Name:
Authentication Facility ID:
VA
Authenticated
16 Sep 2011
Memphis TN VAMC
614
VA Treating Facility
DVA CENTRL ARKNSAS VETERAN HCS
Memphis TN VAMC
VBA BRLS
VETERANS ID CARD SYSTEM
VBA CORP
DEPARTMENT OF DEFENSE DEERS
ENROLLMENT SYSTEM REENGINEERING
AUSTIN MHV
Type
na
na
na
na
na
na
na
na
CONFIDENTIAL
COBIN, FRED
Page 4 of 57
VA Wellness Reminders
Source: VA
Last Updated: 01 Nov 2016 @ 1106
Sorted By: Name (Ascending)
Learn more about these Wellness Reminders by visiting My HealtheVet. Please contact your health care
team with any questions about your VA Wellness Reminders.
Wellness Reminder
Eye Exam for Diabetes
Foot Exam for Diabetes
Lipid Measurement
(Cholesterol)
HbA1c for Diabetes
Colon Cancer Screening
Colon Cancer Screening
Due Date
11 Mar 2017
12 Sep 2017
12 Sep 2017
Last Completed
11 Mar 2016
12 Sep 2016
12 Sep 2016
Location
Memphis TN VAMC
Memphis TN VAMC
Memphis TN VAMC
12 Sep 2017
06 Dec 2023
DUE NOW
12 Sep 2016
06 Dec 2013
UNKNOWN
Body Mass Index more

than 25
Pneumonia Vaccine
DUE NOW
UNKNOWN
DUE NOW
UNKNOWN
Influenza Vaccine
DUE NOW
UNKNOWN
Body Mass Index more

than 25
Influenza Vaccine
Pneumonia Vaccine
Hypertension (High Blood
Pressure)
DUE NOW
UNKNOWN
Memphis TN VAMC
Memphis TN VAMC
DVA CENTRL ARKNSAS
VETERAN HCS
DVA CENTRL ARKNSAS
VETERAN HCS
DVA CENTRL ARKNSAS
VETERAN HCS
DVA CENTRL ARKNSAS
VETERAN HCS
Memphis TN VAMC
DUE NOW
DUE NOW
DUE NOW
UNKNOWN
UNKNOWN
UNKNOWN
Memphis TN VAMC
Memphis TN VAMC
Memphis TN VAMC
CONFIDENTIAL
COBIN, FRED
Page 5 of 57
VA Problem List
Source: VA
Sorted By: Date/Time Entered (Descending) then alphabetically by Problem
Your VA Problem List contains active health problems your VA providers are helping you to manage.
This information is available 3 calendar days after it has been entered. It may not contain active
problems managed by non-VA health care providers. If you have any questions about your information,
visit the FAQs or contact your VA health care team.
Problem: Benign essential hypertension (SCT

38341003)
Provider: ADABALA,JAYA L
Location: Memphis TN VAMC
Status: ACTIVE
Comments: --
Date/Time Entered: 11 Mar

2016 @ 1200
Problem: Diabetes mellitus (SCT 73211009)

2016 @ 1200
Provider:
Location:
Status:
Comments:
ADABALA,JAYA L
Memphis TN VAMC
ACTIVE
--
Problem: Interstitial lung disease (SCT 233703007) Date/Time Entered: 11 Mar

2016 @ 1200
Status: ACTIVE
Comments: -Problem: Tubular adenoma (SCT 444408007)
Provider:
Location:
Status:
Comments:

2016 @ 1200
ADABALA,JAYA L
Memphis TN VAMC
ACTIVE
--
Problem: Vitamin D deficiency (SCT 34713006)

Status: ACTIVE

2016 @ 1200
CONFIDENTIAL
COBIN, FRED
Page 6 of 57
Comments: -Problem: Usual interstitial pneumonia (SCT

700250006)
Provider: WILLIAMS,DAVID I
Status: ACTIVE
Comments: -Problem: Chronic low back pain (SCT 278860009)
Provider:
Location:
Status:
Comments:
Date/Time Entered: 04 Aug

2015 @ 1200
ADABALA,JAYA L
Memphis TN VAMC
ACTIVE
--
Problem: Vitamin D deficiency (ICD-9-CM 268.9)

Provider:
Location:
Status:
Comments:
Date/Time Entered: 14 Oct

2015 @ 1200
Date/Time Entered: 10 Dec

2013 @ 1200
ADABALA,JAYA L
Memphis TN VAMC
ACTIVE
--
Problem: Diverticulosis Of Colon (ICD-9-CM

562.10)
Provider: RAY,QUENTIN PATRICK
Status: ACTIVE
Comments: --
Date/Time Entered: 06 Dec

2013 @ 1200
Problem: Respiratory Bronchiolitis Interstitial Lung Date/Time Entered: 21 Nov

Disease (ICD-9-CM 516.34)
2012 @ 1200
Status: ACTIVE
Comments: -Problem: Colonic Polyps (ICD-9-CM 211.3)
Provider:
Location:
Status:
Comments:
Date/Time Entered: 21 Oct

2011 @ 1200
JONES,JEFFERY LOGAN
Memphis TN VAMC
ACTIVE
--
Problem: Abnormal Liver Function Tests

(ICD-9-CM 794.8)

2011 @ 1200
CONFIDENTIAL
COBIN, FRED
Provider:
Location:
Status:
Comments:
JOHNSON,LYNN
Memphis TN VAMC
ACTIVE
--
Problem: Hyperlipidemia (ICD-9-CM 272.4)

Provider:
Location:
Status:
Comments:

2011 @ 1200
JOHNSON,LYNN
Memphis TN VAMC
ACTIVE
--
Problem: Hypertension (ICD-9-CM 401.9)

Provider:
Location:
Status:
Comments:
Page 7 of 57

2011 @ 1200
JOHNSON,LYNN
Memphis TN VAMC
ACTIVE
--
Problem: Unspecified sinusitis (chronic) (ICD-9-CM Date/Time Entered: 03 Aug

473.9)
2011 @ 1200
Provider: JOHNSON,LYNN
Status: ACTIVE
Comments: --
COBIN, FRED
CONFIDENTIAL
Page 8 of 57
VA Admissions and Discharges

Source: VA
No information was available that matched your selection. However if you were recently discharged,
your summary may be available 3 calendar days after it is completed.
CONFIDENTIAL
COBIN, FRED
Page 9 of 57
VA Notes
Source: VA
Sorted By: Date/Time (Descending)
VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed
and signed by all required members of your VA health care team. If you have any questions about your
information please visit the FAQs or contact your VA health care team.
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
30 Sep 2016 @ 0929

NURSING OPT
Memphis TN VAMC
DOWNEY,SHELAINA Y
DOWNEY,SHELAINA Y
30 Sep 2016 @ 1005
Note
LOCAL TITLE: NURSING OPT

STANDARD TITLE: PRIMARY CARE NURSING NOTE
DATE OF NOTE: SEP 30, 2016@09:29 ENTRY DATE: SEP 30, 2016@09:29:21
AUTHOR: DOWNEY,SHELAINA Y EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
COBIN,FRED JR stated full name and full social security number for
identification. Patient in no acute distress at this time. Patient presents to
Copper Clinic for: B/P and HR check
Allergies: LIPITOR, BENAZEPRIL, ATENOLOL
DATE/TIME
TEMP
9/30/16 @ 0940 98
PULSE RESP BP
PAIN
85
18
145/94 1
Clinical Reminders:
Falling Leaves Nursing (Outpatient):
Assess fall risk on every outpatient at the 1st clinic visit of the
day
Has the patient fallen in the past 12 months?
No falls within the past 12 months.
Does the patient use any ambulatory aids (wheelchair, cane, walker,
furniture)? No
Standard Outpatient Fall Precautions Implemented.
1) Patient encouraged to use his/her stronger side when possible.
COBIN, FRED
CONFIDENTIAL
2) Assess the patient's coordination and balance before assisting

with transfer and mobility activities.
3) Ensure patient is wearing non-slip footwear. If necessary,
give patient treaded socks.
Pain Screen:
Patient denies "experiencing any pain at this time".
Stated pain is: 1
Influenza Vaccine:
Patient received Influenza Immunization at this encounter. Vaccine
administered via Policy #118-10 for Tetanus, Pneumovax and Influenza
Vaccine Administration.
Counseled on benefits and potential adverse reactions associated
with this immunization. Instructed to remain in the clinical area
for 15 minutes after receiving the injection and to immediately
report any s/s of acute distress, SOB, and/or rash. Inactivated
Influenza Vaccine (VIS 8/7/15). Immunization Administered per
Nursing Service Policy #118-10. Patient was given Vaccine
Information Statement (VIS).
Injection Site: Right deltoid
Reaction: none
Vaccine Lot Number: 13749221A Expiration Date: 06/29/2017
Manufacturer: Seqirus Pty,Ltd
Vaccine given is NOT preservative free
Multi Dose Vial Injection
**************************************************************
69 y/o AAM seen in clinic for B/P and HR check. Patient evaluated by PCP on
9/12/16 with asymptomatic tachycardia. Patient started on hydralazine 25mg BID
and continue amlodipine 10mg qday. Patient verbalizes compliance taking
medications as ordered.
Patient ambulatory into clinic, steady gait & upright posture. No assistive
device used. Current b/p 145/94 & HR 85. Patient denies any headache,
dizziness,
or blurry vision.
PCP made aware for evaluation. Patient educated on the following PCP
recommendations:
1. Increase hydralazine 25mg BID-->50mg BID. (Advised to take 2 tablets of
current medication at home twice a day until receives the new prescription in
the mail).
2. Continue limiting sodium in diet.
3. B/P goal 110-145/60-90 and HR 60-95, if above recommended goals notify PACT
clinic.
Page 10 of 57
CONFIDENTIAL
COBIN, FRED
Patient provided PACT team contact information for questions or concerns.

Patient verbalized good understanding of instructions and left clinic in NAD.
/es/ SHELAINA DOWNEY, RN
BSN, RN
Signed: 09/30/2016 10:05
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
12 Sep 2016 @ 1130

E-CONSULT CARDIOLOGY
Memphis TN VAMC
NEWMAN,KEVIN P
NEWMAN,KEVIN P
12 Sep 2016 @ 1133
Note
LOCAL TITLE: E-CONSULT CARDIOLOGY

STANDARD TITLE: CARDIOLOGY CONSULT
AUTHOR: NEWMAN,KEVIN P
EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
*** E-CONSULT CARDIOLOGY Has ADDENDA ***
Time spent on completing consult: 10 minutes
You may substitute hydralazine for another antihypertensive. Would consider
Verapamil instead of Amlodipine. Would also consider Digoxin 0.125 mg daily.
This is an electronic consult, not a face to face visit. This consult is
completed after reviewing the consult request information, the chart and
relevant lab and imaging results. The referring clinician is responsible
for reviewing and implementing these recommendations. The referring
clinician can decide to reconsult in the future or request a face to face
visit.
/es/ KEVIN P. NEWMAN, M.D.
CARDIOLOGY STAFF
Signed: 09/12/2016 11:33
Receipt Acknowledged By:
09/30/2016 09:37
/es/ JAYA L ADABALA
JAYA L ADABALA
09/27/2016 ADDENDUM
STATUS: COMPLETED
Called patient and left a message to contact us at 901-523-8990 at extn 5613 to
discuss about cardiology recommendations.
Page 11 of 57
CONFIDENTIAL
COBIN, FRED
/es/ JAYA L ADABALA

JAYA L ADABALA
Signed: 09/27/2016 15:11
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
12 Sep 2016 @ 0943

PRIMARY CARE
Memphis TN VAMC
ADABALA,JAYA L
ADABALA,JAYA L
12 Sep 2016 @ 1021
Note
LOCAL TITLE: PRIMARY CARE

STANDARD TITLE: PRIMARY CARE NOTE
DATE OF NOTE: SEP 12, 2016@09:43 ENTRY DATE: SEP 12, 2016@09:44
AUTHOR: ADABALA,JAYA L
EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
*** PRIMARY CARE Has ADDENDA ***
Reason for visit:
follow up appt
Subjective:
69 y/o AAM with hx of DM II, HTN, HLD, interstial lung disease, Vit D def is
here for regular follow up appt.
Asymtomatic with his tachycardia. Keep himself well hydrated. Does not use any
inhalers.
BS mostly 130's. Takes metformin.
Review of systems:
ROS have been reviewed but negative.
Physical exam:
DATE/TIME
TEMP PULSE RESP BP
PAIN
9/12/16 @ 0930
97.8
114
18
132/92
Gen: NAD
HEENT:normal
Lungs: CTA
Heart: regular tachy
Abd: normal BS, no bruits. Soft, nontender, no organomegaly or masses
Page 12 of 57
COBIN, FRED
CONFIDENTIAL
Ext: No edema. Pulses +2 and symmetrical

Musculoskeletal: Normal muscle bulk.
Neuro:AO x3, no focal neurologic defecits. gait/balance normal
Skin: no suspicious lesions or rash
COBIN,FRED JR 430-92-2068
Allergies: BENAZEPRIL, LIPITOR,
Adverse Reactions: ATENOLOL,
DOB: 08/06/1947
Active and Recently Expired Outpatient Medications (including Supplies):

Active Outpatient Medications
Status
=========================================================================
1) DEXTRAN 70/HYPROMELLOSE 0.3% OPH SOL INSTILL 1 DROP ACTIVE
IN EACH EYE FOUR TIMES A DAY AS NEEDED - FOR DRY
EYES
2) HYDRALAZINE HCL 25MG TAB TAKE ONE TABLET BY MOUTH ACTIVE
TWICE A DAY
3) METFORMIN 1000MG TAB TAKE ONE TABLET (1,000 MG.) BY ACTIVE
MOUTH TWICE A DAY WITH A MEAL FOR DIABETES.
Inactive Outpatient Medications
Status
=========================================================================
1) ACCU-CHEK AVIVA PLUS TEST STRIP 50/BX USE 1 STRIP AS EXPIRED
DIRECTED
2) AMLODIPINE BESYLATE 10MG TAB TAKE ONE TABLET BY MOUTH EXPIRED
EVERY DAY FOR BLOOD PRESSURE
3) ANALGESIC GREASELESS BALM 90GM TUBE APPLY SMALL
EXPIRED
AMOUNT TO AFFECTED AREA FOUR TIMES A DAY AS NEEDED
4) ERGOCALCIFEROL (VITAMIN D) 50000 UNT CAP TAKE 1
EXPIRED
CAPSULE BY MOUTH ONCE A WEEK TO REPLACE VITAMIN D
5) ROSUVASTATIN CA 20MG TAB TAKE ONE-HALF TABLET BY
EXPIRED
MOUTH EVERY DAY FOR CHOLESTEROL *ADVERSE REACTION
TO ATORVASTATIN, DO NOT CONVERT*
Active Non-VA Medications
Status
=========================================================================
1) Non-VA ASPIRIN 81MG EC TAB 81MG MOUTH EVERY MORNING ACTIVE
2) Non-VA RANITIDINE HCL 150MG TAB 150MG MOUTH TWICE A ACTIVE
DAY
3) Non-VA THERAPEUTIC VITAMIN-MINERAL TAB 1 TABLET MOUTH ACTIVE
EVERY DAY
11 Total Medications
09/12/2016 09:44
**************** CONFIDENTIAL Active OP Meds SUMMARY pg. 1 *****************
DOB: 08/06/1947
------------------------- RXOP - Outpatient Pharmacy ------------------------Drug....................................
Last
Page 13 of 57
COBIN, FRED
CONFIDENTIAL
Rx #
Stat
Qty Issued Filled Rem
METFORMIN 1000MG TAB
7992557 ACTIVE
180 03/11/2016 07/07/2016 (2)
SIG: TAKE ONE TABLET (1,000 MG.) BY MOUTH TWICE A DAY WITH A MEAL FOR
DIABETES.
Cost/Fill: $ 3.74
DEXTRAN 70/HYPROMELLOSE 0.3% OPH SOL
7992555 ACTIVE
15
03/11/2016 06/20/2016 (10)
SIG: INSTILL 1 DROP IN EACH EYE FOUR TIMES A DAY AS NEEDED - FOR DRY EYES
Provider: ATCHERSON,HEATHER N Cost/Fill: $ 1.61
HYDRALAZINE HCL 25MG TAB
7992556 ACTIVE
60
03/11/2016 06/20/2016 (2)
SIG: TAKE ONE TABLET BY MOUTH TWICE A DAY
Cost/Fill: $ 5.71
**************************************************************************
LAB RESULTS LAST 24 HRS - NONE FOUND
RADIOLOGY PROCEDURES - NONE FOUND
Assessment and Plan:
1.Interstial lung disease:Asymptomatic. PFT's from 03/2014 showed mild
restrictive ventilatory affect. Following with pulmonology.
2.Sinus tachycardia: EKG shows sinus HR in 108 with few PVC's. Asymptaomtic.
Allergci to BB. E consult palced to cardiology for advise. Recommended to keep
well hydrated.
3.DM II: A1c pending. Last A1c 5.7. Continue metformin. Goal BS 90-130. If BS
>
140 consistently recommended to notify us.
4.HTN: mildly above goal. Recommended to increase hydralazine to 50 mg from 25
mg bid and continue amlodipine. If BP < 100/50 limit to 25 mg bid. Goal BP
110140/60-90. If bp > 145/90 consistently recommended to notify us.
5.HLD: pending labs. Continue crestor and fish oil supp. Educated to
healthy low fat diet and limit fried/greasy foods.
6.Vit D def: Continue Vit D supp.
7.Colonic polyp/ Tubular adenoma: Last colonoscopy done in 12/2013. Recommended
f/up in 3 yrs.
Disposition: RTC in 6 months with labs:

cbc/cmp/flp/a1c/psa/tsh/ua/umicral/vit D
Health maintainance/preventative medicine :
Page 14 of 57
COBIN, FRED
CONFIDENTIAL
Patient received Patient Information and Patient Education Book.

If patient received medication substitutions per VA Formulary,
written instructions were given about name changes. If patient
was advised to discuss Va formulary substitutions with LMD for
approval, instructed to call telephone care if meds. desired.
Pt. instructed in how to get open access appointment for
urgent problems and telephone care for questions/concerns.
Medications and side effects reveiwed. Instructed
to call/rtc/er if present sx worse/new sx/not improving with plan.
Advised to call for any test or lab results 10 to 14 days
after they are done if hasn't heard from us prior to that.
Advised to call if hasn't received appointment times
for any specialty consults or tests we discussed and
ordered.
Tobacco Screen/Counseling(Provider):
Patient was screened for tobacco use today.
Patient is a lifetime non smoker or user of smokeless tobacco or
electronic cigarettes. (Patient has NEVER USED TOBACCO or SMOKELESS
TOBACCO or ELECTRONIC CIGARETTES OR HAS QUIT MORE THAN 7 YEARS AGO.)
Outpt Med Reconciliation(PROVIDER):
Medications and allergies have been reconciled and reviewed with the
patient and/or caregiver and updated in chart to include both VA and
NON-VA medications (if any), herbals, and over the counter
medications. A printed list of Reconciled Medications has been
supplied to the patient, caregiver, appropriate NON VA agency,
and/or next provider of care, if known. If the next provider of care
is within the VA system, the Medication Reconciliation list can be
viewed on Reports Tab under Health Summary.
Patient and /or caregiver was instructed to carry medication
information at all times in the event of an emergency. Patient
and/or caregiver was instructed to give updated medication list to
other providers and to update the medication list when medications
are discontinued, doses are changed, or new medications (including
over-the counters) are added.
No medication discrepancies were found.
Written instructions were provided to patient/caregiver concerning
the need for follow-up with VA or non VA prescribing provider for
medication management. Prescribing provider and medication:
Pulmonary
No known NON-VA Medications - patient does not use non-VA
medications
Weight Management Counseling:
After discussing the health risks of obesity and referral to MOVE!
or other weight loss programs outside of the VA, the patients
Page 15 of 57
CONFIDENTIAL
COBIN, FRED
refuses referral to MOVE! or other weight loss programs at this

time.
HTN Assess for BP>140/90(Provider):
INTERVENTIONS
The patient's medication regimen was adjusted to improve BP control.
Comment: recommedend to take 50 mg
The patient was counseled on the importance of diet and weight
control in the control of blood pressure.
The contribution of dietary sodium to elevated blood pressure was
reviewed. The patient was counseled to limit sodium intake to no
more than 2.4g of sodium or 6g of sodium chloride.
/es/ JAYA L ADABALA
JAYA L ADABALA
Signed: 09/12/2016 10:21
09/15/2016 ADDENDUM
STATUS: COMPLETED
Called and left a message on his VM about his lab results.
TG eleavted. Educated to eat healthy fat diet and limit fried foods. A1c at
goal. Continue Vit D supp.
Recommend to call at 901-523-8990 at extn 5613 to further discuss about the
antiHTN med changes for better control of HR.
/es/ JAYA L ADABALA
JAYA L ADABALA
Signed: 09/15/2016 15:55
09/19/2016 ADDENDUM
STATUS: COMPLETED
COBIN,FRED JR veried identity stating full name and full social security
number.
Patient educated on PCP recommendations of diet and medication changes.
Hydralazine 25mg BID added; medication indication, dosage, frequency & side
effects reviewed. Patient educated on b/p goal 110-145/60-90, if consistently
>
145/90 notify PACT clinic or if HR consistently >100 notify PACT clinic.
Patient verbalized good understanding.
BSN, RN
Signed: 09/19/2016 11:09
Date/Time:
Note Title:
Location:
Signed By:
12 Sep 2016 @ 0929

MEDICAL ASSISTANT
Memphis TN VAMC
TAYLOR,WANDA M
Page 16 of 57
CONFIDENTIAL
COBIN, FRED
Co-signed By: TAYLOR,WANDA M

Date/Time Signed: 12 Sep 2016 @ 0932
Note
LOCAL TITLE: MEDICAL ASSISTANT

STANDARD TITLE: NURSING NOTE
AUTHOR: TAYLOR,WANDA M
EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
Alcohol Screen (RN/Provider ONLY):
SCREEN FOR ALCOHOL (AUDIT-C)
An alcohol screening test (AUDIT-C) was negative (score=2).
1. How often did you have a drink containing alcohol in the past
year?
Two to four times a month
2. How many drinks containing alcohol did you have on a typical day
when you were drinking in the past year?
1 or 2
3. How often did you have six or more drinks on one occasion in the
past year?
Never
NEGATIVE - TOTAL score
Advance Directives Education:
Patient received Advance Directive screening/education at this
encounter.
day
furniture)? No
Pain Screen:
Page 17 of 57
COBIN, FRED
CONFIDENTIAL
Patient denies "experiencing any pain at this time".

Stated pain is: 0
PTSD Screen (Provider ONLY):
Results of PTSD screening
A PTSD screening test (PTSD 4Q) was negative (score=0).
1. Have had any nightmares about it or thought about it when you did
not want to?
No
2. Tried hard not to think about it or went out of your way to avoid
situations that remind you of it?
No
3. Were constantly on guard, watchful, or easily startled?
No
4. Felt numb or detached from others, activities, or your
surroundings?
No
NEGATIVE - TOTAL score 2 or less
Diabetic Foot Exam:
VASCULAR EXAM: (VIA PALPATION)
Posterior Tibial Pulse Right: Intact
Dorsalis Pedis Pulse Right: Intact
Posterior Tibial Pulse Left: Intact
Dorsalis Pedis Pulse Left: Intact
Documented PAD In L.E.
No
NEUROLOGICAL EXAM:
10 Gram Monofilament Testing Right: Normal
10 Gram Monofilament Testing Left : Normal
normal
SKIN EXAM: no abnormal findings
no findings
ORTHOPEDIC EXAM: no abnormal findings
no findings
FOOT CARE EDUCATION: Educational literature dispensed and daily
foot care instructions were given.
Level of Understanding: Good
ASSESSMENT OF RISK FOR LOWER EXTREMITY AMPUTATION:
NO RISK = Normal pulses. Normal sensory. No deformity. No prior
ulcer
Preferred Healthcare Language:
Veteran's preferred language for discussing health care:
English
Page 18 of 57
CONFIDENTIAL
COBIN, FRED
/es/ WANDA M. TAYLOR

MEDICAL ASSISTANT BHA,MSOM,MCS
Signed: 09/12/2016 09:32
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
03 Aug 2016 @ 0733

PRIMARY CARE SECURE MESSAGING
Memphis TN VAMC
DOWNEY,SHELAINA Y
DOWNEY,SHELAINA Y
03 Aug 2016 @ 0733
Note
LOCAL TITLE: PRIMARY CARE SECURE MESSAGING

STANDARD TITLE: PRIMARY CARE SECURE MESSAGING
DATE OF NOTE: AUG 03, 2016@07:33:51 ENTRY DATE: AUG 03, 2016@07:33:52
URGENCY:
STATUS: COMPLETED
------Original Message-----------------------Sent: 08/02/2016 02:20 PM
From: COBIN, FRED
To: **MEM PACT C-03 PCP (Adabala, J.,) Memphis
Subject: General Inquiry
MY ACC-CHEK AVIVA METER HAVE STOP WORKING WILL VA REPLACE IT NEED TO KNOW
------Original Message-----------------------Sent: 08/03/2016 08:33 AM
From: DOWNEY, SHELAINA
To: COBIN, FRED
Subject: General Inquiry
Mr. Cobin:
Please contact the 1-800 number on the back of the machine. The Aviva customer
service will troubleshoot and assist to fix the machine if possible. If not,
the Aviva company will replace the meter.
Shelaina Downey
RN, BSN

BSN, RN
Signed: 08/03/2016 07:33
Page 19 of 57
CONFIDENTIAL
COBIN, FRED
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
29 Jul 2016 @ 0900

C&P EXAM
PYLE,HOYTE R JR
PYLE,HOYTE R JR
29 Jul 2016 @ 0851
Note
LOCAL TITLE: C&P EXAM

STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: JUL 29, 2016@09:00 ENTRY DATE: JUL 29, 2016@08:51:07
AUTHOR: PYLE,HOYTE R JR EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
Diabetes Mellitus
Disability Benefits Questionnaire
Name of patient/Veteran: CONBIN, FRED JR
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
ACE and Evidence Review
----------------------Indicate method used to obtain medical information to complete this
document:
[X] In-person examination
Evidence Review
--------------Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS
1. Diagnosis
-----------Is there an official diagnosis of Diabetes Mellitus Type I? No
Is there an official diagnosis of Diabetes Mellitus Type II? Yes
ICD code: NA
Page 20 of 57
COBIN, FRED
CONFIDENTIAL
Date of diagnosis: 12/14

2. Medical history
-----------------a. Treatment (check all that apply)
[X] Managed by restricted diet
[X] Prescribed oral hypoglycemic agent(s)
b. Regulation of activities
Does the Veteran require regulation of activities as part of medical
management of diabetes mellitus (DM)? No
c. Frequency of diabetic care
How frequently does the Veteran visit his or her diabetic care provider
for episodes of ketoacidosis? Less than 2 times per month
How frequently does the Veteran visit his or her diabetic care provider
for episodes of hypoglycemia? Less than 2 times per month
d. Hospitalizations for episodes of ketoacidosis or hypoglycemic reactions
How many episodes of ketoacidosis required hospitalization over the past
12 months? 0
How many episodes of hypoglycemic reactions required hospitalization over
the past 12 months? 0
e. Loss of strength and weight
Has the Veteran had progressive unintentional weight loss and loss of
strength attributable to Diabetes Mellitus? No
3. Complications of DM
---------------------a. Does the Veteran have any of the following recognized complications of
DM?
No
b. Does the Veteran have any of the following conditions that are at least
as
likely as not (at least a 50% probability) due to DM? No
c. Has the Veteran's DM at least as likely as not (at least a 50%
probability) permanently aggravated (meaning that any worsening of the
condition is not due to natural progress) any of the following
conditions?
[X] None
4. Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
Page 21 of 57
CONFIDENTIAL
COBIN, FRED
----------------------------------------------------------------------a. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms related to any conditions
listed in the Diagnosis Section above?
[ ] Yes [X] No
b. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
Section above?
[ ] Yes [X] No
c. Comments, if any:
No response provided
5. Diagnostic testing
--------------------Test results used to make the diagnosis of DM (if known): (check all that
apply)
[X] Other, describe:
ABOVE UNKNOWN
Current test results:
Most recent A1C, if available: NA
Date: NA
Most recent fasting plasma glucose, if available: 103
Date: 7-28-16
6. Functional impact
-------------------Does the Veteran's DM (and complications of DM if present) impact his or
her
ability to work? (Impact on ability to work may also be addressed on the
individual Questionnaire(s) for other diabetes-associated conditions and/or
complications, if completed.) No
7. Remarks, if any:
------------------HIS DIABETES IS PRESUMPTIVE TO AGENT ORANGE EXPOSURE.
/es/ HOYTE R PYLE JR

telephone 501-257-2063
Signed: 07/29/2016 08:51
Date/Time: 29 Jul 2016 @ 0900
Note Title: C&P EXAM
Page 22 of 57
CONFIDENTIAL
COBIN, FRED
Location:
Signed By:
Co-signed By:
Date/Time Signed:

PYLE,HOYTE R JR
PYLE,HOYTE R JR
29 Jul 2016 @ 0903
Note

URGENCY:
STATUS: COMPLETED
Knee and Lower Leg Conditions
Name of patient/Veteran: COBIN, FRED JR
Examination
Request?
[X] Yes [ ] No
document:
Evidence Review
[X] CPRS
1. Diagnosis
-----------a. List the claimed condition(s) that pertain to this DBQ:
AS BELOW
b. Select diagnoses associated with the claimed condition(s) (Check all that
apply):
[X] Other (specify):
Page 23 of 57
COBIN, FRED
CONFIDENTIAL
Other diagnosis: RESIDUALS OF LATERAL MENISCUS TEAR.

Side affected: Left
ICD code: NA
Date of diagnosis (left side): INCREASE
********************************************************************
c. Comments (if any):
d. Was an opinion requested about this condition (internal VA only)?
2. Medical history
-----------------a. Describe the history (including onset and course) of the Veteran's
knee
and/or lower leg condition (brief summary):
LOCKING OF LEFT KNEE IN SERVICE IN 1968 THAT BEGAN IN BOOT CAMP. SYMPTOMS
WORSENED AND IN 2/72 HE HAD A LATERAL MENISECTOMY FOR A TORN LEFT LATERAL
MENISCUS.HE IS SC AT 0% AND REQUESTS AN INCREASE. HIS KNEE DOES NOT LOCK,
HAS PAIN AT TIMES.
b. Does the Veteran report flare-ups of the knee and/or lower leg?
[ ] Yes [X] No
c. Does the Veteran report having any functional loss or functional impairment
of the joint or extremity being evaluated on this DBQ, including but not
limited to repeated use over time?
[ ] Yes [X] No
3. Range of motion (ROM) and functional limitation
-------------------------------------------------a. Initial range of motion
Left Knee
--------[ ] All normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Flexion (0 to 140):
Extension (140 to 0):
0 to 120 degrees
120 to 0 degrees
If abnormal, does the range of motion itself contribute to functional

loss? [ ] Yes (please explain) [X] No
Description of pain (select best response):
No pain noted on exam
Page 24 of 57
COBIN, FRED
CONFIDENTIAL
Is there evidence of pain with weight bearing? [ ] Yes [X] No

Is there objective evidence of localized tenderness or pain on palpation of
the joint or associated soft tissue? [X] Yes [ ] No
If yes, describe including location, severity and relationship to
condition(s):
MILD
Is there objective evidence of crepitus? [ ] Yes [X] No
b. Observed repetitive use
Left Knee
--------Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional functional loss or range of motion after three
repetitions? [ ] Yes [X] No
c. Repeated use over time
Left Knee
--------Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after repetitive
use over time:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time.
Please explain.
[X] The examination is neither medically consistent or inconsistent
with
the Veteran's statements describing functional loss with
repetitive
use over time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
d. Flare-ups
e. Additional factors contributing to disability
Left Knee
Page 25 of 57
COBIN, FRED
CONFIDENTIAL
--------In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe: None
4. Muscle strength testing
-------------------------a. Muscle strength - Rate strength according to the following scale:
0/5
1/5
2/5
3/5
4/5
5/5
No muscle movement
Palpable or visible muscle contraction, but no joint movement
Active movement with gravity eliminated
Active movement against gravity
Active movement against some resistance
Normal strength
Left Knee:
Rate Strength:
Flexion:
5/5
Extension:
5/5
Is there a reduction in muscle strength? [ ] Yes [X] No
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
5. Ankylosis
-----------Complete this section if the Veteran has ankylosis of the knee and/or lower
leg.
a. Indicate severity of ankylosis and side affected (check all that apply):
Left Side:
[ ] Favorable angle in full extension or in slight flexion between 0 and
10 degrees
[ ] In flexion between 10 and 20 degrees
[ ] In flexion between 20 and 45 degrees
[ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more
[X] No ankylosis
b. Indicate angle of ankylosis in degrees:
6. Joint stability tests
-----------------------a. Is there a history of recurrent subluxation?
Page 26 of 57
COBIN, FRED
CONFIDENTIAL
Left: [X] None [ ] Slight [ ] Moderate [ ] Severe

b. Is there a history of lateral instability?
Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
c. Is there a history of recurrent effusion?
[ ] Yes [X] No
d. Performance of joint stability testing
Left Knee:
Was joint stability testing performed?
[X] Yes
[ ] No
[ ] Not indicated
[ ] Indicated, but not able to perform
If joint stability testing was performed is there joint instability?
[ ] Yes [X] No
If yes (joint stability testing was performed), complete the section
below:
- Anterior instability (Lachman test)
[X] Normal
[ ] 1+ (0-5 millimeters)
- Posterior instability (Posterior drawer test)
[X] Normal
- Medial instability (Apply valgus pressure to
knee in extension
and with 30 degrees of flexion)
[X] Normal
- Lateral instability (Apply varus pressure to knee in extension
and with 30 degrees of flexion)
[X] Normal
e. Comments, if any:
Page 27 of 57
COBIN, FRED
CONFIDENTIAL
7. Additional conditions
-----------------------a. Does the Veteran now have or has he or she ever had recurrent patellar
dislocation, "shin splints" (medial tibial stress syndrome),
stress
fractures, chronic exertional compartment syndrome or any other tibial
and/or fibular impairment?
[ ] Yes [X] No
b. Comments, if any:
8. Meniscal conditions
---------------------a. Does the Veteran now have or has he or she ever had a meniscus (semilunar
cartilage) condition?
[X] Yes [ ] No
If yes, indicate severity and frequency of symptoms, and side affected:
Left Side:
[X] Meniscal tear
b. For all checked boxes above, describe:
SEE ABOVE HISTORY.
9. Surgical procedures
---------------------Indicate any surgical procedures that the Veteran has had performed and
provide
the additional information as requested (check all that apply):
Left Side:
[X] Meniscectomy, arthroscopic or other knee surgery not described above
Type of surgery: LEFT LATERAL MENISECTOMY
Date of surgery: 2/72
symptoms and scars
-----------------------------------------------------------------------a. Does the Veteran have any other pertinent physical findings, complications,
conditions, signs or symptoms related to any conditions listed in the
Diagnosis Section above?
[ ] Yes [X] No
Page 28 of 57
COBIN, FRED
CONFIDENTIAL
Section above?
[X] Yes [ ] No
If yes, are any of these scars painful or unstable; have a total area
equal to or greater than 39 square cm (6 square inches); or are located
on the head, face or neck? (An "unstable scar" is one where,
for any
reason, there is frequent loss of covering of the skin over the scar.)
[ ] Yes [X] No
If no, provide location and measurements of scar in centimeters.
Location: LEFT KNEE
Measurements: length 5cm X width 0.3cm
11. Assistive devices
--------------------a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion,
although occasional locomotion by other methods may be possible?
[ ] Yes [X] No
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
12. Remaining effective function of the extremities
--------------------------------------------------Due to the Veteran's knee and/or lower leg condition(s), is there
functional
impairment of an extremity such that no effective function remains other than
that which would be equally well served by an amputation with prosthesis?
(Functions of the upper extremity include grasping, manipulation, etc., while
functions for the lower extremity include balance and propulsion, etc.)
[ ] Yes, functioning is so diminished that amputation with prosthesis would
equally serve the Veteran.
[X] No
---------------------a. Have imaging studies of the knee been performed and are the results
available?
[ ] Yes [X] No
b. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No
Page 29 of 57
CONFIDENTIAL
COBIN, FRED
c. If any test results are other than normal, indicate relationship of

abnormal
findings to diagnosed conditions:
--------------------Regardless of the Veteran's current employment status, do the
condition(s)
listed in the Diagnosis Section impact his or her ability to perform any type
of occupational task (such as standing, walking, lifting, sitting, etc.)?
[ ] Yes [X] No
15. Remarks, if any:
-------------------No response provided

Signed: 07/29/2016 09:03
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
29 Jul 2016 @ 0900

C&P EXAM
PYLE,HOYTE R JR
PYLE,HOYTE R JR
29 Jul 2016 @ 0856
Note

URGENCY:
STATUS: COMPLETED
Stomach and Duodenal Conditions
(Not including GERD or esophageal disorders)
Examination
Request?
Page 30 of 57
COBIN, FRED
CONFIDENTIAL
[X] Yes [ ] No
document:
Evidence Review
[X] CPRS
1. Diagnosis
-----------Does the Veteran now have or has he/she ever had any stomach or duodenum
conditions? [X] Yes [ ] No
[X] Duodenal ulcer
ICD code: NA
Date of diagnosis: 1968
2. Medical History
stomach
or duodenum conditions (brief summary):
HOSPITALIZED AND TREATED FOR DUODENAL ULCER IN THE SERVICE IN 1968
WITH
HEALING. SC AT 10%. FOR REVIEW. HAD SOME HEARTBURN AT TIMES AFTER
GETTING OUT OF THE SERVICE. CURRENTLY TAKES TAGAMET OR ZANTAC PRN IF
HE
HAS SYMPTOMS.
b. Does the Veteran's treatment plan include taking continuous
medication for
the diagnosed condition?
[X] Yes [ ] No
If yes, list only those medications used for the diagnosed condition:
AS ABOVE
3. Signs and symptoms
--------------------Does the Veteran have any of the following signs or symptoms due to any
Page 31 of 57
COBIN, FRED
CONFIDENTIAL
stomach or duodenum conditions? [X] Yes [ ] No

If yes, check all that apply:
[X] Recurring episodes of symptoms that are not severe
If checked, indicate frequency of episodes of symptom recurrence per
year:
[ ] 1 [ ] 2 [ ] 3 [X] 4 or more
If checked, indicate average duration of episodes of symptoms:
[X] Less than 1 day [ ] 1-9 days [ ] 10 days or more
[X] Abdominal pain
If checked, indicate severity and frequency (check all that apply):
[X] Occurs at least monthly
[X] Periodic
[X] Relieved by standard ulcer therapy
4. Incapacitating episodes
-------------------------Does the Veteran have incapacitating episodes due to signs or symptoms of
any
stomach or duodenum condition? [ ] Yes [X] No
5. Other conditions
------------------Does the Veteran have any of the following conditions? [ ] Yes [X] No
symptoms and scars
----------------------------------------------------------------------a. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms related to the conditions
listed in the Diagnosis Section above?
[ ] Yes [X] No
Section above?
[ ] Yes [X] No
No answer provided
--------------------a. Have diagnostic imaging studies or other diagnostic procedures been
performed?
[ ] Yes [X] No
b. Has laboratory testing been performed?
Page 32 of 57
CONFIDENTIAL
COBIN, FRED
[ ] Yes [X] No
c. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [ ] No
-------------------Do any of the Veteran's stomach or duodenum conditions impact his or
her
ability to work? [ ] Yes [X] No
9. Remarks, if any:
------------------No remarks provided.

Signed: 07/29/2016 08:56
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
29 Jul 2016 @ 0900

C&P EXAM
PYLE,HOYTE R JR
PYLE,HOYTE R JR
29 Jul 2016 @ 0852
Note

URGENCY:
STATUS: COMPLETED
Hypertension
Examination
Request?
[X] Yes [ ] No
Page 33 of 57
CONFIDENTIAL
COBIN, FRED

document:
Evidence Review
[X] CPRS
1. Diagnosis
-----------Does the Veteran now have or has he/she ever been diagnosed with
hypertension
or isolated systolic hypertension based on the following criteria:
[X] Yes [ ] No
[X] Hypertension
ICD code: NA
Date of diagnosis: APPROX. 2005
2. Medical history
hypertension condition (brief summary):
SEE REMARKS BELOW
b. Does the Veteran's treatment plan include taking continuous
medication for
hypertension or isolated systolic hypertension?
No response provided.
c. Was the Veteran's initial diagnosis of hypertension or isolated
systolic
hypertension confirmed by blood pressure (BP) readings taken 2 or more
times on at least 3 different days?
d. Does the Veteran have a history of a diastolic BP elevation to
predominantly 100 or more?
3. Current blood pressure readings
---------------------------------No response provided.
Page 34 of 57
CONFIDENTIAL
COBIN, FRED
symptoms and scars

----------------------------------------------------------------------No response provided.
-------------------No response provided.
6. Remarks, if any
-----------------HISTORY OF HYPERTENSION SINCE 2005 ACCORDING TO PATIENT. DIAGNOSED WITH
DIABETES IN 12/14. RENAL FUNCTION IS NORMAL. HIS HYPERTENSION WAS NOT
CAUSED BY HIS DIABETES OR AGGRAVATED BY HIS DIABETES. FOT THIS REASON THE
DBQ WAS NOT COMPLETED. HIS HYPERTENSION IS NOT RELATED TO AGENT ORANGE.

Signed: 07/29/2016 08:52
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
16 May 2016 @ 1022

PATIENT TEST RESULTS NOTIFICATION
Memphis TN VAMC
DOWNEY,SHELAINA Y
DOWNEY,SHELAINA Y
16 May 2016 @ 1024
Note
LOCAL TITLE: PATIENT TEST RESULTS NOTIFICATION

STANDARD TITLE: LABORATORY NOTE
DATE OF NOTE: MAY 16, 2016@10:22 ENTRY DATE: MAY 16, 2016@10:22:36
URGENCY:
STATUS: COMPLETED
The following identifiers were used to verify this patient: full name, full SSN
& DOB.
Communicated to patient test results dated 5/12/16.
Mehod of communication of results: Telephone
Labs - abnormal
AST 53 (improved from 60 in March 2016): advised to continue to
limit ETOH intake, eat low fat diet, and avoid acetaminophen
(Tylenol) medication.
Page 35 of 57
CONFIDENTIAL
COBIN, FRED
Patient verbalized good understanding.

BSN, RN
Signed: 05/16/2016 10:24
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
16 Mar 2016 @ 1337

PULMONARY
Memphis TN VAMC
WILLIAMS,DAVID I
WILLIAMS,DAVID I
16 Mar 2016 @ 1341
Note
LOCAL TITLE: PULMONARY

STANDARD TITLE: PULMONARY NOTE
DATE OF NOTE: MAR 16, 2016@13:37 ENTRY DATE: MAR 16, 2016@13:37:43
AUTHOR: WILLIAMS,DAVID I EXP COSIGNER: FREIRE,AMADO X
URGENCY:
STATUS: COMPLETED
Pulmonary Clinic
---------------Reason for Visit: Follow up ILD
HPI: Pt is a 66 yo AAM PMHx HTN, HLP, 3 pneumothoraces (2 left and 1 right- 2
were spontaneous and one was traumatic after MVA 2008, last one 2010) who was
found to have ILD changes on CT chest 2012 and is here for f/u today.
He continues to feel well with no repsiratory complaints. Able to ambulate
without any issues. Denies sob, cough, wheeze. Denies DOE.
No recent hospitalizations/ER visits for respiratory symptoms.
ROS:
Denies fever, chills, nightsweats, hemoptysis, weightloss.
PMedHx:
HTN
HLP
3 Pneumothoraces
ILD
PSurgHx:
DEC 06, 2013 Proc: Colonoscopy
SocHx:
tobacco- 10 pack-year history and quit 2011
Page 36 of 57
COBIN, FRED
CONFIDENTIAL
ETOH- occ
Occupational exposure: Agent orange
FamHx:
No family h/o lung disease; sister had lung cancer.
VITALS - T 98.2 BP 145/87 P 82 POx 99% on RA
GEN: AAOx3 NAD
HEENT: EOMI, PERRL, no oral lesions, no JVD, no LAD
CV: RRR, nl S1,S2, no m/r/g
CHEST: some minimal dry crackles in mid lung fields L>R
ABD: S, NT, ND, +BS
EXT: No c,c,e 2+ pulses
NEURO: No gross focal deficits
Labs/studies:
CTD w/u 2013 negative (anti-Sm Ab, RF, ANA, anti-ccp)
Alpha-1 antitrypsin wnl
PFTs
---PFTs 3/2014
3/2015
FVC 3.05 (65%)
3.28 (70)
FEV1 2.40 (64%)
2.66 (72)
Ratio 79%
81
DLCO 20.1 (77%)
22.1 (90)
__________________________________________________________________________
SPIROMETRY: 9/16/15
FVC
2.93 L (63% predicted)
FEV1 2.35 L (64% predicted)
FEV1/FVC 80%
POST BRONCHODILATORS
FVC
3.04 L (66% predicted)
FEV1 2.50 L (68% predicted)
No evidence of upper airway obstruction via flow volume loop.
Reduced vital capacity suggests presence of a moderate restrictive ventilatory
defect. Clinical correlation suggested.
__________________________________________________________________________
LUNG VOLUMES:
TLC(L): 4.50 L (64% predicted)
RV(L): 1.41 L (53% predicted)
RV/TLC%: 40
Moderate restrictive ventilatory defect.
__________________________________________________________________________
GAS TRANSFER:
DLCO: 20.1 ml/mmHg/min (80% predicted)
Gas transfer is normal.
Page 37 of 57
COBIN, FRED
CONFIDENTIAL
IMAGING
------CT chest 9/24/13
Impression:
1. Extensive interstitial lung disease most likely related to
idiopathic pulmonary fibrosis with no significant change from the
above reference exams. Extensive pleural parenchymal scarring
not significantly changed from previous exams.
2. Stable noncalcified subcentimeter nodules along the minor
fissure.
CT chest 3/2014
Impression:
Interstitial lung disease, basically a nonspecific pattern but I
favor idiopathic pulmonary fibrosis based on the presence of
traction bronchiectasis and presence of both macrocystic and
microcystic honeycombing.
CT chest 3/15/15
Impression:
1. Stable nonspecific interstitial lung pattern with
honeycombing in the periphery of both lungs, most proounced in
the inferior aspect of the lingular segment of the left upper
lobe and posterior basilar portions of both lower lobes. No
significant change in the degree of honeycombing.
2. Traction bronchiectasis to the lower lobes, stable.
3. Although the pattern is nonspecific, I favor idiopathic
pulmonary fibrosis given the traction bronchiectasis and
honeycombing, which is most prevalent in the lower lungs.
4. Several stable, small, noncalified pulmonary nodules right
middle lobe and right lower lobe with stable pleural plaque on
the right mid lung.
5. Old, healed fractures third through eighth ribs on the left.
6MWT 10/14/15
------------Rest: 98% HR 86
Walking 93% HR 140
420 meters
Assessment: 66 yo AAM with PMHx HTN, HLP, 3 pneumothoraces (2 left and 1

right- 2 were spontaneous and one was traumatic after MVA 2008, last one 2010)
Page 38 of 57
CONFIDENTIAL
COBIN, FRED
who was found to have ILD on CT chest 2012 and is here for f/u today.
CT pattern appears UIP/IPF (peripheral honeycombing, traction bronchiectasis
&
reticular lesions) but patient clincally does not fit this picture, with near
normal DLCO and no hypoxia and lesions not progressing much with no treatment
over past ~4yrs now. He remains completely asymptomatic clinically.
Plan:
- stable by clinical assessment, CT chest, PFTs. Pt asx.
- will continue to monitor clincally given no symptoms
- if symptoms return will repeat CT and consider pirfenidone
RTC 1 yr
Flu vaccine up to date
Pneumo vaccine up to date (8/15)
/es/ DAVID I WILLIAMS
PULMONARY/CRITICAL CARE FELLOW
Signed: 03/16/2016 13:41
/es/ AMADO X. FREIRE, M.D.
PULMONARY STAFF
Cosigned: 03/16/2016 13:50
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
11 Mar 2016 @ 1558

OPTOMETRY TECHNICIAN
Memphis TN VAMC
LAXTON,JENNIE G
LAXTON,JENNIE G
11 Mar 2016 @ 1558
Note
LOCAL TITLE: OPTOMETRY TECHNICIAN

STANDARD TITLE: OPTOMETRY TECHNICIAN NOTE
AUTHOR: LAXTON,JENNIE G EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
Optical Coherence Tomography of the optic nerve (RNFL and Post Pole) performed
OU
/es/ JENNIE G LAXTON
ophthalmic technician
Signed: 03/11/2016 15:58
Page 39 of 57
CONFIDENTIAL
COBIN, FRED
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
11 Mar 2016 @ 1414

NURSING OPT
Memphis TN VAMC
JOHNSON,LYNN
JOHNSON,LYNN
11 Mar 2016 @ 1415
Note

AUTHOR: JOHNSON,LYNN
EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
Pt stated name and social security number for identification. Pt in no acute
distress at this time. Pt presents to Copper Clinic for: lab draw as part of
PCP's visit. Pt tolerated procedure well.
Lab obtained from:
_______ Left hand
_______ Right hand
_______ Left forearm
_______ Right forearm
_______ Left antecubital
___x____ Right antecubital
Other:
/es/ Lynn Johnson
LPN
Signed: 03/11/2016 14:15
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
11 Mar 2016 @ 1300

OPTOMETRY
Memphis TN VAMC
ATCHERSON,HEATHER N
ATCHERSON,HEATHER N
11 Mar 2016 @ 1434
Note
LOCAL TITLE: OPTOMETRY

STANDARD TITLE: OPTOMETRY NOTE
DATE OF NOTE: MAR 11, 2016@13:00 ENTRY DATE: MAR 11, 2016@13:01
AUTHOR: ATCHERSON,HEATHER N EXP COSIGNER: WILLIAMSON,JAMES A
URGENCY:
STATUS: COMPLETED
Page 40 of 57
CONFIDENTIAL
COBIN, FRED
Page 41 of 57
This patient's name and SSN have been verified [hna]

CC/HPI: 68 yo AAM presents for comprehensive exam. Patient states that vision is
good, no changes noted. T2 non-insulin dep diabetic for only a little over a
year. Last A1c was 5.7% on 3/11/16.
SC: Patient has h/o DES OU. States that he has been using AT's about 3-4
times
per week with relief. Needs refills.
No other ocular or visual complaints.
ROS: GENERAL:
HEENT: (-)hearing loss
CARDIO: (-)palpitations
RESP: (-)dyspnea
GI/GU: (-)GERD
MUSC: (-)tremors
SKIN: (-)lesions
NEURO/PSYCH: (-)depression
ENDO (-)thyroid condition
HEMATO/LYMPH: (-)anemia
ALLERG/IMMUN: (-)seasonal
Pt is oriented to person, time and place.
Mood/affect are normal.
POHX: LEE: 11/24/14 c DFE, 8/7/15 teleretinal
(+)GLC suspect as of 09/17/11 exam: d/c'd at 12/31/13 exam
(-)Cataract
(-)Surgery
(-)Trauma
(-)Diplopia
(-)floaters
(-)flashes
============================= GLAUCOMA HISTORY ================================
IOP:
09/17/11
10/19/11
05/14/12
12/31/13
11/24/14
03/11/16
16/16 @ 10:57am
No meds
19/18
No meds
18/18 1056
No meds
15/15 @ 1151
No Meds
16/19 @ 8:48am
No meds
16/17
No meds
DILATED FUNDUS EXAM (09/17/11)

C/D: .70H/.75V OD, .75H/.75V OS; thin temp rims OU; healthy rim tissue 360
OU
COBIN, FRED
CONFIDENTIAL
Page 42 of 57
OCT optic nerve (09/17/11):

OD: thinning (red) ST, IT, G; borderline (yellow) T; WNL all others
OS: thinning (red) ST; borderline (yellow) T, IT, G; WNL all others
OCT ONH 05/14/12
OD: (-)progression
OS: (-)progression
ONH OCT: 12/31/2013
RNFL OCT Spectralis:
OD: WNL (Green): SN, N, IN Borderline (Yellow): T Thin (Red):G, ST, IT (-)
progression
OS: WNL (Green): SN, N, IN Borderline (Yellow): T, IT Thin (Red): G, ST (-)
progression
OCT-RNFL 3/11/16:
OD: ONL ST/G/IT, borderline T, all else WNL
OS: ONL ST/G, borderline T/IT, all else WNL
-no change outside of age-related norms since 2011 either eye
OCT-post pole 23/1/1/16:
-no significant inter or intra-eye asymmetry
HVF 24-2 (09/17/11):
OD: Reliable; GHT WNL; no glaucomatous defects noted
OS: Reliable; GHT BDL; mildly dense sup to sup/nasal cluster defect
12/31/2013
OD: MD: -0.08, PSD 1.45, FL 2/13, FN 2%, FP 11%, VFI 100%- reliable- full
field
no defects
OS: MD: +0.00, PSD 1.56, FL 0/13, FN 0%, FP 0%, VFI 99%- reliable- full field
no
defects
Gonio (09/17/11):
OD: CB/TM all quadrants with 1 pigment; flat iris approach 360
OS: CB/TM all quadrants with 1 pigment; flat iris approach 360
Pachs:
OD:584 microns
OS:577 microns
ONH photos 11/24/14.
=============================================================================
PMHX: (+)DM
Collection DT
Spec HGB A1C
03/11/2016 11:17 BLOOD 5.7
08/04/2015 13:09 BLOOD 5.6
COBIN, FRED
CONFIDENTIAL
(+)HTN
Measurement DT BP
03/11/2016 11:20 147/96
03/11/2016 11:18 145/93
03/11/2016 11:11 155/102
(+)Hyperlipidemia
(-)CAD
(-)MI
(-)CVA
(-)Pulmonary Disease
FHX: (-)GLC
(-)Blindness
(-)AMD
SHX: (-)Tobacco
(+)ETOH - occasional
(-)Rec Drugs
Active Outpatient Medications (including Supplies):
Status
=========================================================================
1) AMLODIPINE BESYLATE 10MG TAB TAKE ONE TABLET BY MOUTH ACTIVE
ACTIVE
ACTIVE
ACTIVE
Pending Outpatient Medications
Status
=========================================================================
1) ACCU-CHEK AVIVA PLUS TEST STRIP 50/BX USE 1 STRIP PENDING
MISC EVERY DAY
2) HYDRALAZINE HCL 25MG TAB TAKE ONE TABLET BY MOUTH PENDING
TWICE A DAY
3) METFORMIN 1000MG TAB TAKE ONE TABLET (1,000 MG.) BY PENDING
Status
=========================================================================
DAY
EVERY DAY
Page 43 of 57
COBIN, FRED
CONFIDENTIAL
Allergies/Adverse Reactions:
LIPITOR, BENAZEPRIL, ATENOLOL
DVAcc: OD: 20/20-1
OS: 20/20-2
NVAcc: OU: 20/20
PUPILS: ERRL; (-)APD OU
CVF: FTFC OU
EOMs: FROM OU; (-)pain, (-)diplopia
HRX: OD:+0.25-0.50x100
OS:+0.75-0.75x084
Add: +2.25 PAL
MRX: OD:+0.25 DS
20/20
OS:+0.50-0.25x085
20/20
ADD:+2.25
20/20 OU
SLIT LAMP EXAM
LLL: trace MG capping, MG inspissation OU
CONJ: melanosis OU, large pingueculas N/T OU, trace injection OU
SCLERA: white OU
K: arcus 360 OU, tr SPK OU
TF: oily appearance c mild debris OU, TBUT: 7-8 secs OU
AC: D/Q OU
ANGLES: 3x3 OU
IRIS: normal OU
LENS: 1+ NS OU
TAG: OD: 16 OS: 17 @ 1:15pm - uppper lid held gently
Dilated c 1 gtt of Tropicamide 1% OU @ 1:17pm
DILATED FUNDUS EXAM
C/D: .70H/.75V OD, .75R OS, deep cups OU, thin temp rims OU, ISNT rule
followed OU
MAC: flat, intact OU
BCKGRND: normal OU
VESSELS: 2/3 A/V, 1/3 ALR OU
PERIPH: normal OU,(-)holes, tears, detachments 360 OU
OCT-RNFL 3/11/16:
OD: ONL ST/G/IT, borderline T, all else WNL
OS: ONL ST/G, borderline T/IT, all else WNL
-no change outside of age-related norms since 2011 either eye
OCT-post pole 23/1/1/16:
-no significant inter or intra-eye asymmetry
Page 44 of 57
COBIN, FRED
CONFIDENTIAL
ASSESSMENTS/PLANS
1. T2 non-insulin dep DM s retinopathy OU // Stressed importance of strict
BS/med/PCP compliance. Monitor 1yr c DFE, not eligible for teleretinal photos.
2. Cataracts OU - nuclear // mild, non-surgical at this time. Monitor 1yr c DFE.
3. DES OU - evaporative // Edu veteran on condition and correlating symptoms.
Added refills for hypromellose ATs QID OU. Sending via mail. Monitor 1yr or
sooner if gtts do not relieve symptoms.
4. Open angles with borderline findings, low risk OU // No change in OCT-RNFL
scans since 2011 except within age-related norms. We dc'd suspect status in
2013
due to no change, however because of C/D ratio, continue to monitor as a lowrisk suspect.
-Edu pt on findings
-RTC 1yr for annual c DFE, repeat OCT-RNFL and perform another HVF at
that visit
4. RE c presbyopia OU // SRx no change, cont in HRx for now. Monitor 1yr.
OD:+0.25 DS
OS:+0.50-0.25x085
ADD:+2.25
(expires 3/11/17)
Normal Vision: 20/25 or better: Unspecified disorder of refraction
or acco
mmodation (367.9).
Patient has diabetes.
Patient had a dilated fundus exam.
Patient does not have diabetic retinopathy.
Patient does not have macular degeneration.
Patient has glaucoma.
No documentation of target IOP.
Patient had a dilated fundus exam.
Optic nerve evaluation has been documented.
Scanning laser testing and/or visual field testing were performed.
Findings of the test and if progression have been documented.
Gonioscopy was not performed.
Patient has been referred to specialist for risk for disease
progression and/or non-compliance with medication.
Patient was referred for low vision.
Patient was educated in regards to their future appointment in the eye
clinic. The patient was provided information on the importance of a
follow-up appointment and the appropriate way to reach the clinic to
cancel or reschedule if that becomes necessary.
_________________________________________________________________
VISUAL FIELD
Tests Ordered Include: 24-2
EYE(S)-(OS and OD Requires unilateral 52 procedure modifier code on
encounter form)OU
Distance RX OD:- Sphere:+0.25 Cylinder: Axis:
Distance RX OS:- Sphere:+0.50 Cylinder:-0.25 Axis:85
Page 45 of 57
CONFIDENTIAL
COBIN, FRED
/es/ Heather Atcherson, OD

Optometry Resident
Signed: 03/11/2016 14:34
/es/ JIM WILLIAMSON, OD
OPTOMETRIST
Cosigned: 03/11/2016 15:23
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
11 Mar 2016 @ 1118

PRIMARY CARE
Memphis TN VAMC
ADABALA,JAYA L
ADABALA,JAYA L
11 Mar 2016 @ 1142
Note
LOCAL TITLE: PRIMARY CARE

STANDARD TITLE: PRIMARY CARE NOTE
AUTHOR: ADABALA,JAYA L
EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
*** PRIMARY CARE Has ADDENDA ***
Reason for visit:
follow up appt
Subjective:
68 y/o AAM with hx of DM II, HTN, HLD, interstial lung disease, Vit D def is
here for regular follow up appt.
BS mostly 100's. Is taking metformin.
Denies any SOB.
Review of systems:
Cardiovascular: Denies any chest pain/ palpitations/PND/ orthpnea/ edema
Respiratory:Denis any coughing/ wheezing/ dyspnea/ hemoptysis
Gastrointestinal: Denies any abdominal pain/ dysphagia/ nausea/ vomiting,
diarrhea/ constipation/melena/bloody stools/hematemesis
Neurologic: Denies any syncope/seizures/ transient paralysis/ weakness,
paresthesias
Psychiatric: Denies any depression/anxiety/ mental disturbance/ difficulty
sleeping
Page 46 of 57
CONFIDENTIAL
COBIN, FRED
Physical exam:
DATE/TIME
TEMP
3/11/16 @ 1114
3/11/16 @ 1111 97.8
PULSE
89
RESP
20
BP
PAIN
5
145/93 5
Gen: NAD
HEENT:normal
Lungs: CTA
Heart: RRR
Abd: normal BS, no bruits. Soft, nontender, no organomegaly or masses
Ext: No edema. Pulses +2 and symmetrical
Musculoskeletal: Normal muscle bulk.
Neuro:AO x3, no focal neurologic defecits. gait/balance normal
Skin: no suspicious lesions or rash
Allergies: BENAZEPRIL, LIPITOR,
Adverse Reactions: ATENOLOL,
DOB: 08/06/1947
Active and Recently Expired Outpatient Medications (including Supplies):

Status
=========================================================================
1) AMLODIPINE BESYLATE 10MG TAB TAKE ONE TABLET BY MOUTH ACTIVE
ACTIVE
ACTIVE
ACTIVE
Inactive Outpatient Medications
Status
=========================================================================
1) ACCU-CHEK AVIVA GLUCOSE 1-2 CONTROL SOLN USE TO CHECK EXPIRED
MACHINE MISC AS DIRECTED TO TEST ACCU-CHEK AVIVA
MACHINE
2) FISH OIL 1000MG (500MG DHA/EPA) CAP TAKE ONE CAPSULE EXPIRED
BY MOUTH TWICE A DAY
3) HYPROMELLOSE 0.4% OPHTH SOLN 15ML INSTILL 1 DROP IN EXPIRED
EACH EYE FOUR TIMES A DAY AS NEEDED - FOR DRY EYES
4) NAPROXEN 500MG TAB TAKE ONE TABLET BY MOUTH TWICE A EXPIRED
DAY AS NEEDED TAKE WITH FOOD
Status
=========================================================================
Page 47 of 57
COBIN, FRED
CONFIDENTIAL

DAY
EVERY DAY
03/11/2016 11:18
**************** CONFIDENTIAL Active OP Meds SUMMARY pg. 1 *****************
DOB: 08/06/1947
------------------------- RXOP - Outpatient Pharmacy ------------------------Drug....................................
Last
Rx #
Stat
Qty Issued Filled Rem
ERGOCALCIFEROL (VITAMIN D) 50000 UNT CAP
7225177C ACTIVE
12
08/09/2015 02/05/2016 (2)
SIG: TAKE 1 CAPSULE BY MOUTH ONCE A WEEK TO REPLACE VITAMIN D
Cost/Fill: $ 1.75
AMLODIPINE BESYLATE 10MG TAB
6735043D ACTIVE
90
08/13/2015 01/17/2016 (2)
SIG: TAKE ONE TABLET BY MOUTH EVERY DAY FOR BLOOD PRESSURE
Cost/Fill: $ 1.22
ROSUVASTATIN CA 20MG TAB
6511204D ACTIVE
45
08/09/2015 01/05/2016 (2)
SIG: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR CHOLESTEROL *ADVERSE
REACTION TO ATORVASTATIN, DO NOT CONVERT*
Cost/Fill: $ 38.42
METFORMIN 1000MG TAB
7655487 ACTIVE
180 03/20/2015 12/22/2015 (0)
SIG: TAKE ONE TABLET (1,000 MG.) BY MOUTH TWICE A DAY WITH A MEAL FOR
DIABETES.
Cost/Fill: $ 4.64
ANALGESIC GREASELESS BALM 90GM TUBE
7538595A ACTIVE
90
08/04/2015 12/22/2015 (2)
SIG: APPLY SMALL AMOUNT TO AFFECTED AREA FOUR TIMES A DAY AS NEEDED
Cost/Fill: $ 1.64
**************************************************************************
LAB RESULTS LAST 24 HRS - NONE FOUND
RADIOLOGY PROCEDURES - NONE FOUND
Assessment and Plan:
1.Interstial lung disease:Asymptomatic. PFT's from 03/2014 showed mild
restrictive ventilatory affect. Following with pulmonology.
Page 48 of 57
COBIN, FRED
CONFIDENTIAL
2.DM II: A1c pending. Last A1c 5.6. Continue metformin. Goal BS 90-130. if BS
>
140 consistently recommended to notify us.
3.HTN: mildly above goal. Added hydralazine 25 mg bid and continue amlodipine.
Goal BP 110-140/60-90. If bp > 145/90 consistently recommended to notify us.
4.HLD: pending labs. Continue crestor and fish oil supp. Educated to
healthy low fat diet and limit fried/greasy foods.
5.Vit D def: Continue Vit D supp.
6.Colonic polyp/ Tubular adenoma: Last colonoscopy done in 12/2013. Recommended
f/up in 3 yrs.
Disposition: RTC in 6 months with labs:

cbc/cmp/flp/a1c/psa/tsh/ua/umicral/vit D
Health maintainance/preventative medicine :

Patient received Patient Information and Patient Education Book.
If patient received medication substitutions per VA Formulary,
written instructions were given about name changes. If patient
was advised to discuss Va formulary substitutions with LMD for
approval, instructed to call telephone care if meds. desired.
Pt. instructed in how to get open access appointment for
urgent problems and telephone care for questions/concerns.
Medications and side effects reveiwed. Instructed
to call/rtc/er if present sx worse/new sx/not improving with plan.
Advised to call for any test or lab results 10 to 14 days
after they are done if hasn't heard from us prior to that.
Advised to call if hasn't received appointment times
for any specialty consults or tests we discussed and
ordered.
Lipid Screening(High Risk Pt.):
Blood drawn, results pending
After discussing the health risks of obesity and referral to MOVE!
or other weight loss programs outside of the VA, the patients
refuses referral to MOVE! or other weight loss programs at this
time.
Tobacco Screen/Counseling(Provider):
Patient was screened for tobacco use today.
Patient is a Current Smoker or Uses Smokeless Tobacco or uses
Electronic cigarettes or has QUIT TOBACCO LESS THAN 12 MONTHS.
Patient DECLINES medication to assist with tobacco cessation
Patient received education on Health Risks associated with tobacco
use and was offered smoking
(nicotine) cessation class.
Patient declines referral to smoking (nicotine) cessation class.
Page 49 of 57
COBIN, FRED
CONFIDENTIAL
Level of understanding: Fair

Patient was provided direct brief counseling regarding the tobacco
habit, advised of strategies to quit or stay quit and offered
medication to assist in quitting.
Patient was provided direct brief counseling regarding the tobacco
habit, advised of strategies to quit or stay quit and offered
medication to assist in quitting.
The following was discussed with this patient
*ASKED about tobacco use and if positive,
*ADVISED tobacco user to quit
Identified reasons for and benefits of quitting. Reviewed past
quit attempts - what helped and what led to relapse. "Quitting
smoking is the most important thing you can do to protect your
health".
*ASSESSED readiness to quit
"Are you ready to quit at this time? If no, I understand that you
may not be willing to quit right now, but when you are, it is
helpful to do the following:"
*ASSISTED/PROVIDED strong messages of support and encouragement.
Encouraged tobacco user to set a date ideally within 2 weeks.
*PLAN to address challenges: Get support from family,friends, &
colleagues Anticipate challenges/nicotine withdrawal in effort to
quit or stay quit. Total abstinence is essential. Encourage use
of pharmacotherapy. (Rx: nicotine patch, gum, lozenge or
bupropion:)
*ADVISING the patient to remove all tobacco products from the home
and work. Provided information on tobacco cessation classes
offered through the VA, in the community, and through 1-800-QUIT
NOW.
*ARRANGED for follow-up visits
Provided info for follow-up visits with healthcare provider when
he or she does want assistance in quitting. If relapse occurs,
encourage repeat quit attempts.
HTN Assess for BP>140/90(Provider):
INTERVENTIONS
The patient's medication regimen was adjusted to improve BP control.
Comment: added hydralazine 25 mg bid
The patient was counseled on the importance of diet and weight
control in the control of blood pressure.
The contribution of dietary sodium to elevated blood pressure was
reviewed. The patient was counseled to limit sodium intake to no
more than 2.4g of sodium or 6g of sodium chloride.
Page 50 of 57
CONFIDENTIAL
COBIN, FRED
Outpt Med Reconciliation(PROVIDER):

Medications and allergies have been reconciled and reviewed with the
patient and/or caregiver and updated in chart to include both VA and
NON-VA medications (if any), herbals, and over the counter
medications. A printed list of Reconciled Medications has been
supplied to the patient, caregiver, appropriate NON VA agency,
and/or next provider of care, if known. If the next provider of care
is within the VA system, the Medication Reconciliation list can be
viewed on Reports Tab under Health Summary.
Patient and /or caregiver was instructed to carry medication
information at all times in the event of an emergency. Patient
and/or caregiver was instructed to give updated medication list to
other providers and to update the medication list when medications
are discontinued, doses are changed, or new medications (including
over-the counters) are added.
No medication discrepancies were found.
Written instructions were provided to patient/caregiver concerning
the need for follow-up with VA or non VA prescribing provider for
medication management. Prescribing provider and medication:
pulmonology
Current NON-VA MEDICATION list is accurate
/es/ JAYA L ADABALA
JAYA L ADABALA
Signed: 03/11/2016 11:42
03/15/2016 ADDENDUM
STATUS: COMPLETED
Called and updated lab results.
AST eleavted. Admits to be drinking ETOH more than he should.
Recommended to limit his ETOH intake.
Will repeat LFT's in 10-12 weeks.
Patient agreed and verbalized good understanding.
@ Shealina phone clinic in 10-12 weeks for f/up LFT's. Thanks
/es/ JAYA L ADABALA
JAYA L ADABALA
Signed: 03/15/2016 14:34
Receipt Acknowledged By:
03/15/2016 14:40
BSN, RN
Date/Time: 11 Mar 2016 @ 1113
Note Title: NURSING OPT
Page 51 of 57
CONFIDENTIAL
COBIN, FRED
Location:
Signed By:
Co-signed By:
Date/Time Signed:
Memphis TN VAMC
JOHNSON,LYNN
JOHNSON,LYNN
11 Mar 2016 @ 1115
Note

AUTHOR: JOHNSON,LYNN
EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
Pt stated name and social security number for identification. Pt in no acute
distress at this time. Pt presents to Copper Clinic for:
Pt here with c/o pain to his lower back.

REMINDERS:
Alcohol Screen (RN/Provider ONLY):
SCREEN FOR ALCOHOL (AUDIT-C)
An alcohol screening test (AUDIT-C) was negative (score=1).
1. How often did you have a drink containing alcohol in the past
year?
Monthly or less
2. How many drinks containing alcohol did you have on a typical day
when you were drinking in the past year?
0 drinks
3. How often did you have six or more drinks on one occasion in the
past year?
Never
NEGATIVE - TOTAL score
Clinician documentation that weight management treatment is not
appropriate because the patient has a normal BMI or a BMI 25- 29.9
without obesity associated conditions
day
furniture)? No
Page 52 of 57
CONFIDENTIAL
COBIN, FRED

Pain Screen:
Patient has chronic pain of 3 or greater.
PAIN SCREEN-1st Location/Highest level of pain:
Patient states "experiencing pain" on a scale of 1-10.
Stated pain is: 5
Comment: Pt states pain is controlled.
Location of pain:
Lower, Back
OUTCOME: There will be a 50% reduction in pain (inpatients within
24 hours and outpatients within 2 encounters). Select at three
interventions to achieve this goal. For pharmacological
interventions see Pain Management Policy.
Depression Screen-RN/PROVIDER ONLY:
Results of PHQ-2
A PHQ-2 screen was performed. The score was 0 which is a negative
screen for depression.
1. Little interest or pleasure in doing things
Not at all
2. Feeling down, depressed, or hopeless
Not at all
NEGATIVE - TOTAL score 2 or less
Learning Needs Assessment/Barriers:
Learning Needs Assessment done during this encounter - No Barriers
Noted
Education done.
Level of Understanding: Good Person who received the education:
Patient
/es/ Lynn Johnson
LPN
Signed: 03/11/2016 11:15
Date/Time:
Note Title:
Location:
Signed By:
Co-signed By:
Date/Time Signed:
Note
10 Mar 2016 @ 0814

TELEPHONE/VISN PROGRAM SUPPORT ADMINISTRATIVE
Memphis TN VAMC
BEARD,NATHANIEL
BEARD,NATHANIEL
10 Mar 2016 @ 0814
Page 53 of 57
COBIN, FRED
CONFIDENTIAL
LOCAL TITLE: TELEPHONE/VISN PROGRAM SUPPORT ADMINISTRATIVE

STANDARD TITLE: ADMINISTRATIVE NOTE
AUTHOR: BEARD,NATHANIEL EXP COSIGNER:
URGENCY:
STATUS: COMPLETED
Patient was called to inform of pending appointment tomorrow @ 2:00pm
Response:
(x) Confirmed Appointment
( ) Voicemail
( ) No Answer
( ) #Dissconnected
( ) Wrong #
( ) Left Message W/ Family Member
( ) Patient Cancelled Appointment
( ) NO # Listed
( ) Busy Signal
*Reminded to fast & arrive early to get labs drawn in clinic.
/es/ NATHANIEL BEARD
MSA
Signed: 03/10/2016 08:14
Page 54 of 57
COBIN, FRED
CONFIDENTIAL
Page 55 of 57
DoD Military Service Information

Source: DoD
NOTES:
1) This report may not show your complete DoD Military Service Information.
For more information go to the FAQ tab. Data prior to establishment of
DEERS and full service reporting (c. 1980) may not appear.
2) It is normal for the begin/end dates in DoD records, adjusted by the
Personnel Center after separation, to vary slightly from the DD-214.
3) No peacetime deployments will be displayed. For Gulf War I, only one
period will be displayed even if you deployed more than once. No conflict
prior to Gulf War I will be displayed. Kosovo, Bosnia, and Southern Watch
data is incomplete and may not display.
4) For Guard/Reserve, periods of active duty may not display. No periods of
Active duty service less than 30 days will display.
-- Regular Active Service
Service
Begin Date End Date
Character of Service
Rank
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Marine Corps 10/11/1967 06/17/1969 Honorable
-- Reserve/Guard Association Periods
Service
Begin Date End Date
Character of Service
Rank
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Reserve/Guard Activation Periods
Service
Begin Date End Date
Activated Under (Title 10, 32, etc.)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Deployment Periods
Service
Begin Date End Date
Conflict
Location
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- DoD MOS/Occupation Codes
-- Note: Both Service and DoD Generic codes may not be present in all records
Service
Begin Date Enl/Off
Type
Svc Occ Code
DoD Occ Code
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Military/Combat Pay Details
Service
Begin Date End Date
Military Pay Type
Location
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Separation Pay Details
Service
Begin Date End Date
Separation Pay Type
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Retirement Periods
Service
Begin Date End Date
Retirement Type
Rank
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- DoD Retirement Pay
Service
Begin Date End Date Dsblty % Pay Stat Term Rsn Stop Pay Rsn
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
CONFIDENTIAL
COBIN, FRED
Page 56 of 57
Translations of Codes Used in this Section:

Service Occupation Codes
DoD Occupation Codes
Military Pay Type Code
01
Combat Zone Tax Exclusion (CZTE)
02
Hostile Fire/Imminent Danger
03
Hazardous Duty incentive
Separation Pay Type Code
01
Separation Pay
02
Readjustment Pay
03
Non-Disability Severance Pay
04
Disability Severance Pay
05
Discharge Gratuity
06
Death Gratuity
07
Special Separation Benefit
08
Voluntary Separation Incentive Pay
09
Voluntary Separation Pay (VSP)
Retirement Type Code
A
Mandatory
B
Voluntary
C
Fleet Reserve
D
Temporary Disability Retirement List
E
Permanent Disability Retirement List
F
Title III
G
Special Act
H
Philippine Scouts
Z
Unknown
Retired
1
2
3
4
5
Pay Status Code

Receiving retired pay
Eligible, not receiving pay
Eligible, not receiving direct SBP remittance
Terminated
Suspended
Retired
C
S
Code
W
Pay Termination Reason Code

Pay condition terminated
Pay terminated for the reason reported in the Stop Payment Reason
Not terminated
Stop Payment Reason Code

A
Member died
B
Recalled to Active Duty
C
Removed from TDRL, returned to Active Duty
D
Removed from TDRL, returned to Civilian
E
Pay suspended, failure to report for TDRL physical
F
Civil Service retirement waiver
G
VA compensation waiver
H
Dual compensation, pay cap offset
J
Refused retired pay
K
Pay suspended, whereabouts unknown
L
Suspected death
COBIN, FRED
M
Z
CONFIDENTIAL
Page 57 of 57
Pay suspended, miscellaneous

Not applicable
END OF MY HEALTHEVET PERSONAL INFORMATION REPORT

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CONFIDENTIAL

Personal Information Report

Name: COBIN, FRED

Date of Birth: 06 Aug 1947

Download Request Summary

01 Nov 2016 @ 1148

My HealtheVet Account Summary

Body Mass Index more

Body Mass Index more

Problem: Benign essential hypertension (SCT

Date/Time Entered: 11 Mar

Problem: Diabetes mellitus (SCT 73211009)

Date/Time Entered: 11 Mar

Problem: Interstitial lung disease (SCT 233703007) Date/Time Entered: 11 Mar

Date/Time Entered: 11 Mar

Problem: Vitamin D deficiency (SCT 34713006)

Date/Time Entered: 11 Mar

Comments: -Problem: Usual interstitial pneumonia (SCT

Date/Time Entered: 04 Aug

Problem: Vitamin D deficiency (ICD-9-CM 268.9)

Date/Time Entered: 14 Oct

Date/Time Entered: 10 Dec

Problem: Diverticulosis Of Colon (ICD-9-CM

Date/Time Entered: 06 Dec

Problem: Respiratory Bronchiolitis Interstitial Lung Date/Time Entered: 21 Nov

Date/Time Entered: 21 Oct

Problem: Abnormal Liver Function Tests

Date/Time Entered: 03 Aug

Problem: Hyperlipidemia (ICD-9-CM 272.4)

Date/Time Entered: 03 Aug

Problem: Hypertension (ICD-9-CM 401.9)

Date/Time Entered: 03 Aug

Problem: Unspecified sinusitis (chronic) (ICD-9-CM Date/Time Entered: 03 Aug

VA Admissions and Discharges

30 Sep 2016 @ 0929

LOCAL TITLE: NURSING OPT

2) Assess the patient's coordination and balance before assisting

Patient provided PACT team contact information for questions or concerns.

12 Sep 2016 @ 1130

LOCAL TITLE: E-CONSULT CARDIOLOGY

/es/ JAYA L ADABALA

12 Sep 2016 @ 0943

LOCAL TITLE: PRIMARY CARE

Ext: No edema. Pulses +2 and symmetrical

Active and Recently Expired Outpatient Medications (including Supplies):

Disposition: RTC in 6 months with labs:

Health maintainance/preventative medicine :

Patient received Patient Information and Patient Education Book.

refuses referral to MOVE! or other weight loss programs at this

12 Sep 2016 @ 0929

Co-signed By: TAYLOR,WANDA M

LOCAL TITLE: MEDICAL ASSISTANT

Patient denies "experiencing any pain at this time".

/es/ WANDA M. TAYLOR

03 Aug 2016 @ 0733

LOCAL TITLE: PRIMARY CARE SECURE MESSAGING

/es/ SHELAINA DOWNEY, RN

29 Jul 2016 @ 0900

LOCAL TITLE: C&P EXAM