CONTACTS
SUBJECTS
Endoscopy Test Reflux Esophagitis VA Martinez Background Follow Up E
3003 -
3003 - ..
3004 - Summary/Objective
3005 -
300501 - Follow up ref SDS 51 0000. ref SDS 46 0000.
300502 -
300503 - Checked in at GI Clinic on 2nd floor, and gave Ron's cell phone for
300504 - ride home. ref SDS 0 PP8W During pre-proc preparation, ref SDS 0
300505 - YM9F, doctor explained that continuing swallowing problems after
300506 - surgery to resolve achalasia on 091216, may be caused by esophagitis
300507 - where acid reflux in the stomach swells the throat. ref SDS 0 OP9O
300508 - Examination and endoscopy test show esophagus looks the same. The
300509 - doctor dialated the esophagus and increased medication to relieve
300510 - swelling and enable better swallowing, with reexamination in 4 months.
300511 - ref SDS 0 0466 Medical records on doctor's progress notes provide
300512 - excellent report on background with reasons for testing, ref SDS 0
300513 - LB6J, medications used for anesthesia, and EGD test procedures.
300514 - ref SDS 0 JE4S Findings cite "ulceration esophagus." ref SDS 0 JF4Q
300515 -
300516 -
300517 -
300518 -
300519 -
300520 -
300521 -
300522 -
300524 - ..
3006 -
3007 -
3008 - Background
3009 -
300901 - On 090908 1130 Doctor Lee prepared work plan, ref SDS 9 BU6W, for
300902 - treating achalasia and including resolving new symptom of chest pains.
300903 - ref SDS 9 FT6M
300905 - ..
300906 - On 091002 met with Doctor Egan, Cardiologist at the VA. The doctor
300907 - advised that 10 of 11 test points in the stress test showed positive
300908 - for circulation problems, and so the doctor ordered angiogram.
300909 - ref SDS 10 1W5I
300911 - ..
300912 - 091021 0716 Meeting at VA to complete angiogram test meeting,
300913 - ref SDS 11 01F9, and perform test. ref SDS 11 025B Results show
300914 - requirement for heart bypass surgery. ref SDS 11 7L47
300916 - ..
300917 - On 091022 0700 Doctor Tseng, Casey and others performed quadruple
300918 - heart bypass surgery at VA in San Francisco. ref SDS 12 01F9
300920 - ..
300921 - On 091031 0730 discussed scheduling surgery to fix achalasia problem
300922 - as essential predicate to maintain nutrition required for recovering
300923 - from heart surgery. ref SDS 15 PW5H
300925 - ..
300926 - On 091103 Paula reported the VA has scheduled a meeting today with
300927 - Doctor Stewart for planning Heller Myotomy surgery to correct
300928 - achalasia problem. ref SDS 17 PS60 On 091104 0718 Medical Chart
300929 - discharge guidance lists meeting with Doctor Stewart 091117 1300,
300930 - which conflicts with patient history today. ref SDS 18 Q03J On 091119
300931 - 1000 Erick confirmed visit with Doctor Stewart on 091208, and is
300932 - reviewing date of surgery scheduled for 091217. ref SDS 20 935H
300934 - ..
300935 - On 091104 0718 discharged from VA recovering from quadruple heart
300936 - bypass surgery, ref SDS 18 PR4V, performed on 091022 0700. ref SDS 12
300937 - PQWU; received medical record with list of medications, also on 091104
300938 - 0718, ref SDS 18 1Q6P, and follow up meetings. ref SDS 18 9T6O
300940 - ..
300941 - On 091208 Doctor Stewart advanced the schedule for surgery one day to
300942 - 091216. ref SDS 22 6E41
300944 - ..
300945 - On 091216 0600 meeting Doctor Stewart for Heller Myotomy surgery to
300946 - correct achalasia; check in at ASU. ref SDS 26 PP8W
300948 - ..
300949 - On 091217 0600 meeting with Joe and Jon on recovring from Heller
300950 - Myotomy surgery; report of complication during surgery on 091216,
300951 - which was repaired, with plan for test to evaluate recovery. reported
300952 - on 091217 0600, ref SDS 27 0042 Doctor Stewart visited and expects
300953 - can start eating after favorable test. ref SDS 27 027A
300955 - ..
300956 - On 091218 0600 xray with gastrogafin to evaluate repair for
300957 - complicaiton during Heller Myotomoy surgery Wednesday, ref SDS 28 PP8W,
300959 - ..
300960 - On 091219 0600 doctor plans discharge tomorrow after evaluating
300961 - progress eating solid food today. ref SDS 29 PP5V Since now eating
300962 - solid food, switched to oral pill medication to replace IV injections;
300963 - this relieved pain that has been increasing using IV catheters set on
300964 - Wednesday, ref SDS 29 PQPX, and also eliminated need to replace IV
300965 - catheters per TCU protocol. ref SDS 29 7Q55 Doctors prescribed hiking
300966 - to recover from Heller Myotomy surgery resolving achalasia.
300967 - ref SDS 29 7Q6P Doctor Ratcliff and Neil visit and discussing doing a
300968 - small business trial to apply SDS technology for upgrading VA and UCSF
300969 - case management. ref SDS 29 0M6S Nurse advises that patient approved
300970 - for moving to a ward for non-critical care, as a predicate to
300971 - discharge, but since there are no rooms available, patient will remain
300972 - in TCU untill a room is available. ref SDS 29 0M8S
300974 - ..
300975 - On 091220 0527 discharge approved from hospital today. ref SDS 30 PP8W
300976 - Left the hospital about 1220. ref SDS 30 HB5O
300978 - ..
300979 - On 091221 1532 Isagani called to schedule meeting with Doctor Stewart
300980 - at VA in San Francisco on 100105. ref SDS 31 PP8W
300982 - ..
300983 - On 091222 1109 letter from Isagana says meeting with Doctor Stewart is
300984 - scheduled on 100112 1400. ref SDS 32 PP8W
300986 - ..
300987 - On 091223 1452 letter came in regular mail scheduling a meeting with
300988 - Doctor Stewart on 100105 1400. ref SDS 33 PP8W
300990 - ..
300991 - On 100104 0930 met with Doctor Sandhu to begin care for heart surgery
300992 - and follow up on Heller Myotomy surgery to recover from achalasia.
300993 - ref SDS 36 PP8W
300995 - ..
300996 - On 100305 1000 reported to VA Martinez for endoscopy and colonoscopy
300997 - tests. ref SDS 38 PP8W Doctor Lee ordered shingles vaccination,
300998 - ref SDS 38 4O4O, and this was performed. ref SDS 38 GT5G Endoscopy
300999 - test found evidence of "acid burn" on "flap", ref SDS 38 PR6P;
301000 - treatment prescribed, and plan for follow up test. ref SDS 38 HB86
301001 - Colonoscopy test found no evidence of cancer or disease. ref SDS 38
301002 - K97H
301004 - ..
301005 - On 100610 1046 went to VA in Martinez for blood draw to evaluate
301006 - cholesterol as a diagnostic of cardiovascular health. ref SDS 42 QV4F
301008 - ..
301009 - On 100721 0800 visit Doctor Sandhu Martinez VA; patient demonstrates
301010 - continuing recovery from heart surgery last October, ref SDS 46 PP8W;
301011 - doctor concerned patient is not listening because Simvastatin
301012 - medication to control cholesterol was not continued after completing
301013 - initial prescription, ref SDS 46 3X4L, shown by lab results cholesterol
301014 - has not declined very much for lab on 100610. ref SDS 46 HY76; doctor
301015 - increased dose of Simvestatin and encourages continuing this
301016 - medication. ref SDS 46 RP4F New lab ordered today shows cholesterol
301017 - reversed long-term decline and increased dramatically in just 30 days,
301018 - suggesting possibly error in lab testing process. ref SDS 46 E19L
301020 - ..
301021 - On 100810 1530 meeting with Doctor Lee to schedule a meeting on 100827
301022 - to do another test to evaluate recovery from acid infection found in
301023 - the test last March. ref SDS 51 PP8W The doctor did not address
301024 - questions on severity of reflux esophagitis, ref SDS 51 HN8I, from
301025 - reviewing pathology report received on 100312, ref SDS 40 QQ7O, for
301026 - the endocsopy test on 100305. ref SDS 38 PR6P
301028 - ..
301029 - On 100827 0830 test for improveent in throat since infection found
301030 - during test on 100305. ref SDS 0 PP8W
301031 -
301032 -
301034 - ..
3011 -
3012 -
3013 - Progess
3014 -
301401 - EGD Test Administration Check In Driver Verified
301402 -
301403 - Meeting today with Doctor Lee performs endoscopy test to evaluate
301404 - improvement or progression of reflux esophagitis from findings
301405 - reported in the pathology report received on 100312, ref SDS 40 MX5K
301406 - from the endoscopy test the doctor performed on 100305 1000.
301407 - ref SDS 38 PR6P
301408 -
301409 - [On 100917 1213 ordered CD with Doctor's notes and results
301410 - of biopsy performed today. ref SDS 57 C75G
301412 - ..
301413 - [On 101014 1145 received CD with the VA's medical records
301414 - for meeting on 100827, with the doctor. ref SDS 60 FX6G
301416 - ..
301417 - Thanks to Ron Junior being designated driver required for endoscopy
301418 - test that entails anesthestics -- arrived at VA Clinic in Martinez
301419 - about 0738. [...planned in the letter to Ron Junior on 100825 1022.
301420 - ref SDS 53 6N5J and Ron's reply on 100826 1603. ref SDS 54 6N5J...]
301421 - Ron asked if he needs to come in and verify he will be designated
301422 - driver. This was not presented as a required procedure during the
301423 - visit on Wednesday, 100825 0947, ref SDS 52 6N5J
301425 - ..
301426 - Checked in. Filled out patient fact sheet explaining work to be
301427 - performed, and designating the driver.
301429 - ..
301430 - The attendant asked if the designated driver was present? Explained
301431 - that Ron just left, but is on call with his cell phone number. The
301432 - attendant said that VA procedure requires verification that the driver
301433 - is available by seeing the person in the Clinci at this time. We
301434 - reviewed the meeting on Wednesday, when Kendhell did not say that the
301435 - driver must arrive with the patient prior to the procedure - indicated
301436 - only that VA requires a cell phone, which the attendant will call and
301437 - verify the driver will be available. 100825 0947, ref SDS 52 6N78
301439 - ..
301440 - The attendant smiled and said...
301441 -
301442 - "Don't worry honey! Everybody's always changing things around
301443 - here.!"
301444 -
301445 - [On 100827 2347 letter thanks Ron for ride to VA, reports
301446 - minor glitches, and discussion with the attendant.
301447 - ref SDS 55 PP8W
301449 - ..
301450 - [On 101015 1547 instructions for next EGD test scheduled
301451 - for 101210, states driver must be present at check in.
301452 - ref SDS 61 NC7V
301454 - ..
301455 - Doctor Mesgar was in the Dermatology Control Center on the 2nd floor,
301456 - and spoke with her briefly about concern of possible flare up of prior
301457 - problems with skin on the nose. She commented that the skin looks
301458 - okay, and suggested scheduling a meeting.
301459 -
301460 -
301462 - ..
3015 -
3016 -
3017 - 0852
3018 -
301801 - Acid Reflux Causes Esophagus to Swell Continuing Restrict Swallowing
301802 -
301803 - Called into OR to get prepared for EGD procedure.
301804 -
301805 - [On 100912 1127 letter from Doctor Lee, ref SDS 56 1W5I,
301806 - explaining endoscopy EGD findings, and biopsy (dated
301807 - 100903) show no cancer, pre-cancerous tissue, nor
301808 - infection, but did find severe acid reflux damage in the
301809 - esophagus, ref SDS 56 1W79, which aligns with findings
301810 - shown above on 100827 0728, ref SDS 0 JF4Q, and previously
301811 - described in the biopsy report received on 100312 for the
301812 - EGD on 100305, as "reflux esophagitis." ref SDS 40 MX5K
301814 - ..
301815 - Jennifer was one of the nurses who assisted with the procedure today.
301817 - ..
301818 - Blood pressure about 123 67 pulse 58 - good numbers.
301820 - ..
301821 - For some reason the Pre-procedure Checklist was not performed today,
301822 - which was done for the prior procedure on 100305, ref SDS 38 P86K, and
301823 - including erroneous notice that Advance Directive is not on file.
301824 - ref SDS 38 MV6M
301826 - ..
301827 - Asked doctor to comment on severity of "reflux esophagitis" shown in
301828 - pathology report received from the VA on 100312, ref SDS 40 QQ7O, and
301829 - showing findings for the endocsopy test on 100305, ref SDS 38 PR6P, to
301830 - evaluate recovery from acahalasia following surgery at the VA on
301831 - 091216. ref SDS 26 KE9U
301833 - ..
301834 - Doctor Lee indicated that reflux esophagitis found in EGD test on
301835 - 100305, caused the throat to swell up so swallowing is now restricted,
301836 - despite corrective surgery for achalasia to open previously closed
301837 - esophageal sphincter valve, performed by Doctor Stewart on 091216.
301838 - ref SDS 26 KE9U
301840 - ..
301841 - Asked the doctor to report in Progress Notes initial LESV and final
301842 - LESV after dilation in order to assess progress and anticipate
301843 - swallowing challenges for the period ahead.
301845 - ..
301846 - Doctor Lee indicated he will report numerical results on dilating
301847 - LESV. He expects LESV will be improved to about 13 mm, and he will
301848 - try expanding to 16 mm.
301849 -
301850 - [...below on 100827 0738 at 1244 after the procedure met
301851 - with Doctor Lee, who advised condition of LESV is about the
301852 - same as prior EGD dilation 5 months ago on 100305.
301853 - ref SDS 0 0466
301855 - ..
301856 - [...below on 100827 0738 Progress Notes seem to report LESV
301857 - was expanded with pneumatic (balloon) dilation from initial
301858 - contition to 12.9 then again to 14 and finally to 15 mm.
301859 - ref SDS 0 JE6X
301861 - ..
301862 - Considered that lower WBC from 11 to 7 may reflect improved condition
301863 - of reflux esophagitis.
301865 - ..
301866 - The test today will evaluate whether additional procedure is required.
301867 -
301869 - ..
3019 -
3020 -
3021 - 0928
3022 -
302201 - IV set waiting for Doctor Lee to finish with the first patient.
302202 -
302203 - Had to do the IV twice. Kendall put the first one below the elbow to
302204 - accomodate using the keyboard. Had difficulty getting blood flow,
302205 - similar to Alex at VA in San Francisco Medical Center for Heller
302206 - Myotomy surgery on 091216 0600. ref SDS 26 IG4J
302208 - ..
302209 - The second needle puncture got better blood flow. Glad we didn't
302210 - need a third.
302211 -
302212 - [On 101210 0930 IV successful on 1st needle puncture for
302213 - follow up EGD. ref SDS 63 DM4G
302215 - ..
302216 - Now ready for the procedure, just waiting for the doctor, expected to
302217 - be about 1030.
302218 -
302220 - ..
3023 -
3024 -
3025 - 0948
3026 -
302601 - Waiting to begin procedure.
302602 -
302604 - ..
3027 -
3028 -
3029 - 0949
3030 -
303001 - Begin procedure in operating room.
303002 -
303003 - Gargel think substance "Lidocaine" and swallow to numb the throat,
303004 - following procedure for prior EGD on 100305 1000. ref SDS 38 HB50
303005 -
303006 - [...below medical chart does not list throat gargle for
303007 - numbing throat, nor of Licocaine. ref SDS 0 JE9V
303009 - ..
303010 - Research on the Internet finds...
303012 - ..
303013 - Lidocaine for Throat Pain...
303014 -
303015 - Steadyhealth.com...
303016 -
303017 - http://www.steadyhealth.com/lidocaine_for_throat_pain_from_radiation_treatment_t64130.html
303018 -
303019 - ...[doctor] may prescribe viscous lidocaine (numbing agent)
303020 - or some type of "Miracle Mix" to assist in her comfort if her
303021 - mucositis is especially bad.
303023 - ..
303024 - Nurse injects Fentanyl, and then the anesthetic, reported in Medical
303025 - Record Progress Notes, below. ref SDS 0 JE9V
303027 - ..
303028 - Medical chart provides an excellent report on the actual procedure,
303029 - shown below. ref SDS 0 JE4S
303031 - ..
303032 - Asked the nurse to ask the doctor if reflux esophagitis can cause
303033 - diminished voice, which has been a problem lately. The nurse indcated
303034 - that reflux esophagitis can affect the voice.
303035 -
303037 - ..
3031 -
3032 -
3033 - 1244
3034 -
303401 - Medication Doubled Dose Increase Recovery Esophagitis
303402 - Esophagus Dialated 11-15mm Swallowing Restriction Swelling Acid Reflux
303403 -
303404 - Wake up from procedure.
303405 -
303406 - Nurse calls Ron for a ride.
303408 - ..
303409 - Doctor Lee feels the condition is about the same as for the test on
303410 - 100305. ref SDS 38 Y65G So, there has been no evident improvement
303411 - with treatment since last March, contrary to expectations discussed
303412 - this morning, per above. ref SDS 0 QM9J
303413 -
303414 - LESV Dilated
303415 - Date from to
303416 - 100827 11 15.................... ref SDS 0 JE6X
303417 - 100305 11 15.................... ref SDS 38 WR6L
303419 - ..
303420 - [...below on 100827 0738 Progress Notes seem to report LESV
303421 - was expanded with pneumatic (balloon) dilation from initial
303422 - contition to 12.9 then again to 14 and finally to 15 mm.
303423 - ref SDS 0 JE6X
303425 - ..
303426 - [On 100912 1127 letter from Doctor Lee, ref SDS 56 1W5I,
303427 - explaining endoscopy EGD findings, and biopsy (dated
303428 - 100903) show no cancer, pre-cancerous tissue, nor
303429 - infection, but did find severe acid reflux damage in the
303430 - esophagus, ref SDS 56 1W79, which aligns with findings
303431 - shown above on 100827 0728, ref SDS 0 JF4Q, and previously
303432 - described in the biopsy report received on 100312 for the
303433 - EGD on 100305, as "reflux esophagitis." ref SDS 40 MX5K
303435 - ..
303436 - He showed 4 photographs.
303437 -
303438 - F: 05 00003 60 10 10 0601.DOC
303439 -
303440 - [On 101014 1145 received CD with a Microsoft Word file that
303441 - has the photographs taken today. ref SDS 60 MY6K
303443 - ..
303444 - The doctor indicated that dark areas of esophagus indicate continuing
303445 - swelling that restricts swallowing. The doctor therefore dilated the
303446 - esophagus in increments using "savory dialatores 12, 14, and 15," as
303447 - reported in the Medical Chart, below. ref SDS 0 JE6X
303449 - ..
303450 - He feels dilation breaks up scar tissue to improve widening of
303451 - esophagus, so swallowing will be easier.
303453 - ..
303454 - Doctor Lee advised that he has doubled prescription for medication
303455 - with Omeprazole 20 mg from once to twice daily, as shown in Doctor
303456 - Sandhu's list of medications reported on 100721 0800, ref SDS 46 QG6L,
303457 - and reported by Marcia a few days after prior EDG and dilation on
303458 - 100308 1411. ref SDS 39 CH3O For some reason the medical chart for
303459 - prior EGD and dilation does not prescribe any medication, reported on
303460 - 100305 1000. ref SDS 38 Y65V
303462 - ..
303463 - Omeprazole 40 mg per day is now prescribed, as a result of findings
303464 - today.
303466 - ..
303467 - [...below, medical chart reports medication with Omeprazole
303468 - 20 mg doubled to 40 mg per day. ref SDS 0 MZ8J
303470 - ..
303471 - [On 101210 0930 Doctor Lee prescribes doubling dose again
303472 - to Omeprazole 80 mg per day after EGD and dilation found
303473 - continuing esophagael sphincter severely restricts
303474 - swallowing, ref SDS 63 ZN4M, and shown in medical chart
303475 - Recommendations. ref SDS 63 XT5N
303477 - ..
303478 - Re-examination in November.
303479 -
303480 - [...below, medical chart calls for reexamination in
303481 - November. ref SDS 0 JF8X
303482 -
303483 - [On 101012 1449 Jennifer called for Doctor Lee and
303484 - scheduled follow up EGD test on 101210 0930. ref SDS 59
303485 - 5R5H
303487 - ..
303488 - Requested letter confirming understandings from discussion on test
303489 - today, and follow up work plan for case management as requested
303490 - previously for the test on 100305, ref SDS 38 HB4K, and implemented
303491 - with the doctor's letter dated 100326, and received on 100331 1448.
303492 - ref SDS 41 CG6K
303493 -
303494 - [On 100912 1127 received Doctor Lee's letter confirming
303495 - findings from test today, and setting out follow up work
303496 - plan. ref SDS 56 1W5I
303498 - ..
303499 - [On 101014 1145 received VA medical records with doctor's
303500 - progress notes for procedure on 100827. ref SDS 60 U455
303501 -
303502 -
303503 -
303505 - ..
3036 -
3037 -
3038 - 1333
3039 -
303901 - Ron arrives for ride home. Explains mix up today getting impression
303902 - at noon, that I had already left the clinic.
303903 -
303904 -
303905 -
3040 -
SUBJECTS
VA Medical Records Progress Notes Endoscopy Tests GI Gastroenterolog
6403 -
640401 - ..
640402 - VA Medical Record Meeting for EGD Test
640403 - Endoscopy EGD 60111 Gastroenterology Procedure Note
640404 -
640405 - Follow up ref SDS 38 Y65G.
640406 -
640407 - Following VA Progress Notes were not received until months after the
640408 - work was performed today, reported on 101014 1145. ref SDS 60 U455
640409 -
640410 - F:\05\00003\SM\CC\AGMJ\20100827-083030\medit.txt
640412 - ..
640413 - LOCAL TITLE: EGD 60111.............. ref DRP 1 YE7O
640414 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
640415 - DATE OF NOTE: AUG 27, 2010@08:30
640416 - ENTRY DATE: AUG 27, 2010@16:00:31
640418 - EXP COSIGNER:
640419 - URGENCY:
640420 - STATUS: COMPLETED
640421 - *** EGD 60111 Has ADDENDA ***
640424 - ..
640425 - 1. NAME OF PROCEDURE: ........................... ref DRP 1 NI4H
640426 -
640427 - 1. Esophagogastroduodenoscopy.
640428 - 2. Endoscopic biopsy.
640429 - 3. Wire guide dilation of esophageal stricture.
640431 - ..
640432 - 2. ATTENDING PHYSICIAN: Randall E. Lee, M.D. ....... ref DRP 1 NI4M
640433 -
640434 - [On 101014 1145 received CD from VA with this
640435 - medical record for doctor's progress notes on EGD
640436 - procedure on 100827, and included biopsy report
640437 - dated 100903. ref SDS 60 U455
640439 - ..
640440 - 3. INDICATIONS:
640443 - ...[patient...] is a 65-year-old man with a history of
640444 - achalasia. He underwent a laparoscopic myotomy at the San
640445 - Francisco VA in 12/09. He had an esophagogastroduodenoscopy
640446 - follow up in 03/10. [...EGD test was actually on 100305 1000.
640447 - ref SDS 38 Y65G...] This showed a distal esophageal stricture
640448 - at 38 cm [...reported on 100305 1000. ref SDS 38 Y65V...] with
640449 - associated erosions, as well as a dilated atonic esophageal
640450 - body and a distorted gastric fundus, consistent with his prior
640451 - history of fundoplication. Biopsies showed no evidence of
640452 - Helicobacter pylori or malignancy, but did show evidence of
640453 - reflux esophagitis. [...shown in biopsy report received on
640454 - 100312 1119. ref SDS 40 MX5K...] The stricture was dilated to
640455 - 14 mm. ref DRP 1 ID5G
640457 - ..
640458 - 4. The patient was instructed to use Omeprazole, but his use has
640459 - been inconsistent. ref DRP 1 KF6H
640460 -
640461 - [...below doctor cites possible inconsistent use of
640462 - Omeprazole again in "Impression." ref SDS 0 JE9J
640464 - ..
640465 - This appears to reflect discussion during a meeting at the VA on
640466 - 100810, ref SDS 51 M18F, explaining use of Omeprazole was affected by
640467 - lack of express instructions, following meeting for EGD test on
640468 - 100305, ref SDS 38 HB86, and by illegible handwriting in Discharge
640469 - documents after EDG test on 100305, ref SDS 38 HC7K, and which caused
640470 - delay by the VA ordering Omeprazole, reported by Marcia on 100308
640471 - 1411. ref SDS 39 V55H
640472 -
640473 - [On 101207 1000 Doctor Lee reviewed patient history showing
640474 - Omeprazole taken according to prescription, ref SDS 62
640475 - WH4G, listed in case study on 101010. ref SDS 58 QJ5I
640477 - ..
640478 - VA Medical Cart for 100827 continues...
640479 -
640480 - 5. This procedure is undertaken for a repeat evaluation and repeat
640481 - dilation, as he has begun experiencing additional dysphagia.
640482 - ref DRP 1 VG6L
640484 - ..
640485 - 6. For the details of the history and physical examination, please
640486 - see the associated Gastroenterology Attending Clinic note.
640487 - ref DRP 1 HI3F
640489 - ..
640490 - Cannot find "Gastroenterology Attending Clinic note" in the record
640491 - received from the VA. Could this be the "Indications" section, per
640492 - above? ref SDS 0 JE67 There is a very detailed "clinic note" on
640493 - patient history and physical examination for the prior EGD test on
640494 - 100305; does this record intend to incorporate the prior record?
640495 - ref SDS 38 ZH6I
640497 - ..
640498 - VA Medical Cart for 100827 continues...
640499 -
640500 - 7. CONSENT: The risks, benefits and alternatives to this
640501 - procedure, including but not limited to the risks of bleeding
640502 - and bowel perforation, were explained to the patient. The
640503 - patient understood and provided written informed consent.
640504 - ref DRP 1 8J3J
640506 - ..
640507 - Section on consent and pre-procedure check list is much less detailed
640508 - for the EGD test today than shown for the EGD test on 100305 1000,
640509 - ref SDS 38 K54H, which includes assessment of patients cognitive and
640510 - emotional ability to give conscious and reasoned consent. ref SDS 38
640511 - KB6Y, including patient's being given sufficient notice to make
640512 - "informed" consent. ref SDS 38 TL3N Is the record for the prior test
640513 - incorporated by reference to save time and expense performing
640514 - redundant record keeping?
640516 - ..
640517 - VA Medical Cart for 100827 continues...
640518 -
640519 - 8. INTRAVENOUS MEDICATION:,,,,,,,,,,,,,,,,,, ref DRP 1 0257
640520 -
640521 - 1. Diphenhydramine 50 mg.
640522 - 2. Fentanyl 150 mcg.
640523 - 3. Midazolam 4 mg.
640525 - ..
640526 - This section for EGD procedure does not seem to be in the medical
640527 - record for the same test on 100305. Was this scope called by another
640528 - name in the prior work reported in the record 100305 1000? ref SDS 38
640529 - Y65G Oddly, prior EGD has extensive "sedation plan," which is
640530 - missing from the medical chart for the work today, also, shown on
640531 - 100305 1000. ref SDS 38 W35M
640533 - ..
640534 - For some reason, there is no record of gargling with viscous throat
640535 - numbing agent Lidocaine (??), mentioned by the team, per meeting
640536 - above. ref SDS 0 PSQS
640538 - ..
640539 - The record for the prior colonoscopy test has a section for....
640540 -
640541 - Procedural Sedation Medications.... ref SDS 38 OE8H
640542 -
640543 - 1. Versed 5 mg IV total
640544 - 2. Fentanyl 250 mcg IV total
640545 - 3. Benadryl 50 mg IV total
640547 - ..
640548 - Was there no comparable protocol for the EGD test on 100305?
640550 - ..
640551 - VA Medical Cart for 100827 continues...
640552 -
640553 - 9. DESCRIPTION OF PROCEDURE:................... ref DRP 1 HM4I
640554 -
640555 - In the Martinez VA GI Endoscopy Unit, the patient was placed in
640556 - the left lateral decubitus position. Oxygen at 2 liters per
640557 - minute by nasal cannula was administered. Continuous oximetric
640558 - and hemodynamic monitoring was initiated. Intravenous sedation
640559 - was administered in divided doses.
640561 - ..
640562 - This is an excellent report on surgical procedure for EGD, and brings
640563 - credit to the VA and Doctor Lee for advancing medical best practice.
640564 - While less complicated, it follows the pattern of Neil's report for
640565 - heart surgery on 091022 0700, ref SDS 12 LO3G
640567 - ..
640568 - This section carefully explaining details of EGD procedure does not
640569 - seem to be in the medical chart for the prior test on 100305 1000.
640570 - ref SDS 38 Y65G
640572 - ..
640573 - VA Medical Chart continues...
640574 -
640575 - 10. After a bite block was placed in the patient's mouth, an
640576 - Olympus GIFH180 video gastroscope was advanced under direct
640577 - vision to the distal esophagus. Between 38-39 cm, an
640578 - esophageal stricture was encountered. This impeded smooth
640579 - passage of the endoscope, but yielded with gentle pressure.
640580 - ref DRP 1 HM53
640582 - ..
640583 - 11. The endoscope was then advanced to the descending duodenum.
640584 - Retroflexed views of the incisura, fundus and cardia were
640585 - performed. Directed biopsies were obtained within the
640586 - esophageal stricture at 39 cm and labeled specimen A.
640587 - ref DRP 1 HM54
640589 - ..
640590 - Photographs of internal conditions were received later...
640591 -
640592 - F: 05 00003 60 10 10 0601.DOC
640593 -
640594 - [On 101014 1145 received CD with a Microsoft Word file that
640595 - has the photographs taken today. ref SDS 60 MY6K
640597 - ..
640598 - VA Progress Notes continue...
640599 -
640600 - 12. A Savary guidewire was advanced through the endoscope and the
640601 - distal tip of the wire was positioned within the antrum of the
640602 - stomach. The endoscope was removed, leaving the guidewire in
640603 - place. ref DRP 1 HM66
640605 - ..
640606 - 13. Tapered dilators #12.9, 14 and 15 mm were advanced over the
640607 - guidewire and then removed. Repeat endoscopic examination
640608 - showed no evidence of perforation. ref DRP 1 HM65
640610 - ..
640611 - This appears to report LESV dilated incrementally from initial
640612 - condition of about 11 mm to 12.9 mm, then increased to 14 mm, and
640613 - finally again to 15 mm, in order to widen LESV for swallowing by
640614 - gravity, since LESV has lost muscle control from brain signals to
640615 - expand for swallowing, reported during meeting on 100202 1400.
640616 - ref SDS 37 485W
640617 -
640618 - LESV Dilated
640619 - Date from to
640620 - 100827 11 15.................... ref SDS 0 JE6X
640621 - 100305 11 15.................... ref SDS 38 WR6L
640623 - ..
640624 - [...above on 100827 0738 at 1333 during post procedure
640625 - meeting, Doctor Lee reported condition of LESV at about 11
640626 - mm is about same as during initial EGD dilation on 100305,
640627 - so there has been no evident improvement. ref SDS 0 0466
640629 - ..
640630 - [On 101210 0930 followed up, ref SDS 64 UW5F record of next
640631 - EGD dilation indicates LESV dilated 11 mm to 15 mm.
640632 - ref SDS 63 H347
640634 - ..
640635 - Progress Notes on 100827 continue...
640636 -
640637 - 14. There was a plaque approximately 1 cm in diameter with raised
640638 - edges at 35 cm. This was tattooed with a submucosal injection
640639 - of ink using an ERBElift device, then biopsied and labeled
640640 - specimen B. The stomach and esophagus were decompressed and
640641 - the gastroscope removed. ref DRP 1 HM77
640643 - ..
640644 - 15. COMPLICATIONS: None.
640646 - ..
640647 - 16. FINDINGS:
640648 -
640649 - 1. Oval-shaped esophageal plaque about 1 cm in diameter with
640650 - raised edges, biopsied and tattooed.
640651 -
640652 - 2. Distal esophageal stricture with ulceration between 38-39
640653 - cm.
640655 - ..
640656 - Research found on Internet...
640657 -
640658 - Ulcer-cure.com
640659 -
640660 - http://www.ulcer-cure.com/Types/esophageal-ulcers.php
640661 -
640662 - Esophageal Ulcers
640664 - ..
640665 - Esophageal ulcers occur in the lower end of your
640666 - esophagus. These ulcers are often associated with a bad
640667 - case of acid reflux, or GERD as it is commonly called
640669 - ..
640670 - Esophageal Ulcers are defined as open sores or lesions in
640671 - the lining of the esophagus (the tube that carries food
640672 - from your throat to your stomach). These ulcers usually
640673 - cause pain that is felt behind or just below your
640674 - breastbone, similar to the area where you would feel
640675 - heartburn symptoms.
640677 - ..
640678 - Curiously, have never felt pain the throad, only a drowning feeling
640679 - that requires vomitting to relieve pressure in the throat.
640681 - ..
640682 - Ulcer-cur.com continues...
640683 -
640684 - Healing is slow and these ulcers can recur quite often.
640685 - Chronic and severe recurrences can result in a narrowing
640686 - of your esophagus after healing.
640687 -
640688 - Your esophagus does not have the same mucous lining that
640689 - your stomach has to protect itself against your stomach
640690 - acid. When excessive stomach acid refluxes from your
640691 - stomach up into your esophagus, it can corrode the lining
640692 - of your esophagus over a relatively short period of time.
640693 - This eventually leads to inflammation of the esophagus
640694 - (known as esophagitis), and then later to ulceration.
640696 - ..
640697 - Prolonged or severe acid reflux (severe heartburn) causes
640698 - changes in the cells that line the esophagus. These cells
640699 - then become pre-cancerous, and finally cancerous. Cancer
640700 - is estimated to occur in 10% of patients with acid reflux.
640702 - ..
640703 - Esophageal cancer is currently the fastest growing cancer
640704 - in the western world. The two biggest risk factors for
640705 - this type of cancer are Acid reflux (GERD) and Barrett's
640706 - esophagus.
640708 - ..
640709 - Esophageal narrowing and Barrett's esophagus (an abnormal
640710 - lining of the bottom part of the esophagus) are long-term
640711 - complications from esophagitis (inflammation of the
640712 - esophagus). Barrett's esophagus is also know Barrett's
640713 - syndrome, and is a marker for severe reflux and a sure
640714 - sign of onset of esophageal cancer.
640716 - ..
640717 - Biopsy on 100305 EGD test made express findings that Barrett's disease
640718 - was not found, reported on 100312. ref SDS 40 V38O
640720 - ..
640721 - Ulcer-cur.com continues...
640722 -
640723 - In 1998 surveys showed that esophageal cancer was one of
640724 - the 10 leading cancers causing death among men in the USA.
640726 - ..
640727 - People who have Barrett's esophagus are at increased risk,
640728 - as are people who have long standing acid reflux problems.
640730 - ..
640731 - Medical Chart Progress Notes Findings continue...
640732 -
640733 - 3. Atonic esophageal body.
640735 - ..
640736 - 4. Distorted fundus consistent with known fundoplication.
640738 - ..
640739 - 5. Gastric antral erythema without erosions or
640740 - ulcerations.
640742 - ..
640743 - 6. Normal pylorus.
640745 - ..
640746 - 7. Normal duodenum to D2.
640748 - ..
640749 - 17. IMPRESSION:
640750 -
640751 - 1. Clinical significance of the esophageal plaque is unknown.
640752 - This may have been trauma from the dilation. However,
640753 - biopsies were taken to determine the presence or absence of
640754 - malignancy.
640756 - ..
640757 - 2. Recurrent esophageal stricture possibly due to reflux.
640758 - However, additional biopsies were taken today to determine
640759 - the presence or absence of malignancy. The patient's
640760 - inconsistent use of Omeprazole may be contributing to rapid
640761 - recurrence of a reflux stricture. There may also be
640762 - scarring from the patient's myotomy.
640764 - ..
640765 - Inconsistent use of Omeprazole is also cited in summary above,
640766 - ref SDS 0 JE7X, and as noted appears to reflect discussion during a
640767 - meeting at the VA on 100810, ref SDS 51 M18F, explaining use of
640768 - Omeprazole was affected by lack of express instructions, following
640769 - meeting for EGD test on 100305, ref SDS 38 HB86, and by illegible
640770 - handwriting in Discharge documents after EDG test on 100305,
640771 - ref SDS 38 HC7K, and which caused delay by the VA ordering Omeprazole,
640772 - reported by Marcia on 100308 1411. ref SDS 39 V55H
640774 - ..
640775 - [On 101207 1000 Doctor Lee reviewed patient history showing
640776 - Omeprazole taken according to prescription, ref SDS 62
640777 - WH4G, listed in case study on 101010. ref SDS 58 QJ5I
640779 - ..
640780 - Doctor's Impression continues...
640781 -
640782 - 3. Gastritis previously identified.
640784 - ..
640785 - 18. RECOMMENDATIONS:
640786 -
640787 - 1. Await the pathology results. [...published on 100903,
640788 - received on 100912, and reported in the record today, shown
640789 - below. ref SDS 0 PVXX...]
640791 - ..
640792 - 2. Boost Omeprazole to 20 mg twice a day 15 minutes before a
640793 - meal.
640794 -
640795 - [...aligns with discussion following EGD and dilation
640796 - procedure, per above. ref SDS 0 SG8M
640798 - ..
640799 - For some reason the medical chart on prior EGD and dilation does not
640800 - prescribe any medication, reported on 100305 1000. ref SDS 38 Y65V;
640801 - however Marcia called a few days later and advised that the doctor
640802 - prescribed Omeprazole 20 mg per day, reported on 100308 1411.
640803 - ref SDS 39 CH3O
640805 - ..
640806 - Doctor's Recommendations continues...
640807 -
640808 - 3. If the biopsies are benign anticipate a repeat
640809 - esophagogastroduodenoscopy with dilation in early 11/10.
640810 -
640811 - [...below, in this record on 100827 0728 report dated
640812 - 100903, and entered in this record (received later on
640813 - 101014), shows biopsies benign. ref SDS 0 PVXX
640815 - ..
640816 - [On 101012 1449 Jennifer called for Doctor Lee and
640817 - scheduled follow up EGD test on 101210 0930. ref SDS 59
640818 - 5R5H
640820 - ..
640821 - Aligns with doctor's work plan discussed after recovery today, per
640822 - above. ref SDS 0 SG8M
640824 - ..
640825 - Doctor's Impression continues...
640826 -
640827 - 19. DISPOSITION:
640828 -
640829 - 1. The patient was observed in the Recovery Room and then
640830 - discharged to home with a companion.
640832 - ..
640833 - 2. I reviewed the endoscopic findings with the patient prior
640834 - to discharge. ref SDS 0 JF4Q
640836 - ..
640837 - 20. Dictated: 08/27/10
640838 - Transcribed: 08/27/10
640839 - Job Number: 1159072
640840 - JLS/PSI
640841 - $END
640842 -
640844 - ..
640846 - STAFF PHYSICIAN, GASTROENTEROLOGY
640847 - Signed: 09/03/2010 17:29
640848 -
640849 -
640850 -
6409 -
SUBJECTS
Biopsy Report Dated 100903 EGD Test VA 100827 Cancer Malignancy Not
A403 -
A40401 - ..
A40402 - Biopsy EGD Test Results Cancer Not Found
A40403 -
A40404 - 09/03/2010 ADDENDUM STATUS: COMPLETED
A40406 - ..
A40407 - Following VA biopsy report was received on a CD months after the work
A40408 - was performed today, reported on 101014 1145. ref SDS 60 2T3G
A40410 - ..
A40411 - 1. Microscopic exam/diagnosis: (Date Spec taken: Aug 27,
A40412 - 2010)..... ref DRP 1 PRQW
A40413 -
A40414 - A. ESOPHAGUS AT 39CM (BIOPSY):
A40415 -
A40416 - [On 101014 1145 received CD from VA with medical
A40417 - records for doctor's progress notes on EGD procedure
A40418 - on 100827, and included this report report dated
A40419 - 100903. ref SDS 60 U455
A40421 - ..
A40422 - 1. ULCER BASE WITH FIBRUNOPURULENT DEBRIS AND GRANULATION
A40423 - TISSUE
A40425 - ..
A40426 - 2. SQUAMOUS MUCOSA WITH FOCAL ACUTE INFLAMMATION
A40428 - ..
A40429 - 3. NO EVIDENCE OF MALIGNANCY IDENTIFIED
A40431 - ..
A40432 - B. ESOPHAGUS, PLAQUE AT 35CM (BIOPSY):
A40433 -
A40434 - 1. SQUAMOUS MUCOSA WITH CHANGES OF REFLUX ESOPHAGITIS AND
A40435 - FRAGMENTS OF GRANULATION TISSUE
A40436 -
A40437 - 2. NO EVIDENCE OF MALIGNANCY IDENTIFIED
A40439 - ..
A40440 - [On 100912 1127 letter from Doctor Lee, ref SDS 56
A40441 - 1W5I, explaining endoscopy EGD findings, and biopsy
A40442 - (dated 100903) show no cancer, pre-cancerous tissue,
A40443 - nor infection, but did find severe acid reflux
A40444 - damage in the esophagus, ref SDS 56 1W79, which
A40445 - aligns with findings shown above on 100827 0728,
A40446 - ref SDS 0 JF4Q, and previously described in the
A40447 - biopsy report received on 100312 for the EGD on
A40448 - 100305, as "reflux esophagitis." ref SDS 40 MX5K
A40450 - ..
A40451 - [On 101014 1145 received CD from VA with medical
A40452 - records for doctor's progress notes on EGD procedure
A40453 - on 100827, and included this report report dated
A40454 - 100903. ref SDS 60 U455
A40456 - ..
A40457 - 3. PAS-F STAIN FOR FUNGUS IS NON-CONTRIBUTORY
A40459 - ..
A40460 - 2. In Reply Refer To:
A40461 -
A40470 -
A40471 -
A40472 -
A40473 -
A40474 -
A405 -