571172 - ..
571173 - There are two pictures of the lower esophageal sphincter valve. The
571174 - first looks highly coated. The doctor seemed to indicate this was
571175 - taken prior to removing food buildup from stricture blockage. The
571176 - picture after cleanup seems entirely clear of disease.
571177 -
571178 - 
571180 - ..
571181 - Biopsies and the doctor's narrative in the medical chart will further
571182 - clarify findings from the work today.
571183 -
571184 - [below, pathology report on biopsy supports findings of
571185 - esophagitis, but no cancer from EGD procedure.
571186 - ref SDS 0 PTPU
571188 - ..
571189 - Doctor Lee advised that the esophageal sphincter valve was dilated
571190 - from 11 to 14 mm today. This is slightly less than dilation to 15 mm
571191 - reported last August on 100827 0738. ref SDS 47 JE6X He plans another
571192 - EGD procedure in February for further dilation to 17 mm.
571193 -
571194 - LESV Dilated
571195 - Date from to
571196 - 101210 11 14.................... ref SDS 0 H347
571197 - 100827 11 15.................... ref SDS 47 JE6X
571198 - 100305 11 15.................... ref SDS 39 WR6L
571200 - ..
571201 - [...below on 101210 0930 Progress Notes report LESV was
571202 - inflated sequentially to 12, 13, and 14 mm. ref SDS 0 H347
571204 - ..
571205 - [...below on 101210 0930 Progress Notes report Doctor
571206 - Lee's work plan to eventually dilate esophagus to 17 mm.
571207 - ref SDS 0 NP6R
571209 - ..
571210 - Doctor Lee further prescribed doubling Omeprazole 40 mg to 80 mg,
571211 - which means taking 2 pills twice a day. Posted change in prescription
571212 - to case study reported on 101010 0744. ref SDS 48 MT6G
571213 -
571215 - ..
571216 - Swallowing Degraded After Prior EGD Dilation Increased Vomitting
571217 - Vomitting Increased Swallowing Degraded After Prior EGD Dilation
571218 - Dilate LESV 14 MM and Double Omeprazole 80 MG to Improve Swallowing
571219 - Omeprazole 80 MG and Dilate LESV 14 MM to Improve Swallowing
571220 -
571221 - Asked Doctor Lee about improving swallowing, which degraded severely
571222 - the past 3 or 4 weeks, following prior EGD and dilation procedure on
571223 - 100827, ref SDS 47 PSQS, as reported in case study on 101010,
571224 - ref SDS 48 BT8N, cited in the agenda for the meeting today and
571225 - submitted to the VA on 101206 1542, ref SDS 59 7Q8X, and further
571226 - reviewed with the doctor the next day on 101207, ref SDS 61 WH4N, to
571227 - prepare for work today.
571229 - ..
571230 - The doctor feels that dilating esophageal sphincter to 14 mm today,
571231 - shown in Progress Notes below, ref SDS 0 H347, together with doubling
571232 - prescription to take Omeprazole 80 mg per day will help relieve
571233 - swallowing problems that severely worsened following prior EGD and
571234 - dilation procedure on 100827.
571235 -
571236 - LESV Dilated
571237 - Date from to
571238 - 101210 11 14.................... ref SDS 0 H347
571239 - 100827 11 15.................... ref SDS 47 JE6X
571240 - 100305 11 15.................... ref SDS 39 WR6L
571242 - ..
571243 - [On 110218 0730 next meeting for EGD dilation reported
571244 - improved swallowing after EGD dilation to 14 mm today on
571245 - 101210, and doubling Omeprazole 80 mg per day. However,
571246 - improvement soon degraded causing continual difficulty
571247 - swallowing, ref SDS 76 SR4G, evident from reports on
571248 - vomitting in case study on 101010 0744. ref SDS 48 X85F
571250 - ..
571251 - [On 110218 0730 work plan changed to improve swallowing and
571252 - avoid vomitting by adding injection of about 2 mL of
571253 - triamcinolone acetate 40 mg/mL into the esophageal
571254 - stricture site. ref SDS 76 A296
571256 - ..
571257 - Original prescription taking 1 pill per day of Omeprazole 20 mg was
571258 - reported on 100308 1411, ref SDS 40 CH3O, clarifying discussion with
571259 - the doctor a few days earlier following the 1st EGD dilation procedure
571260 - on 100305 1000. ref SDS 38 HB86 At that time, the medical chart for
571261 - initial EGD and dilation procedure only list "Findings," and do not
571262 - present Impressions and Recommendations. There was was no
571263 - prescription for any medication, also, reported on 100305 1000.
571264 - ref SDS 38 Y65V
571265 -
571266 - [...below medical chart reports recommendation to double
571267 - the dose of Omeprazole 20 mg to 40 mg. ref SDS 0 XT5N
571269 - ..
571270 - [On 101216 1021 VA pharmacy website seems to indicate
571271 - Doctor Lee ordered new prescription for Omeprazole, so not
571272 - necessary to order refill with current prescription running
571273 - out. ref SDS 66 PL6O
571275 - ..
571276 - [On 101216 1021 at 1201 letter to VA GI Department in
571277 - Martinez, requests confirmation that refill on Omeprazole
571278 - was ordered by the doctor, and that the name for the
571279 - prescription number on the VA's online pharmacy is for
571280 - Omeprazole. ref SDS 66 K44P
571282 - ..
571283 - [On 101218 1642 stomach pain, fatigue, and severe dry feet
571284 - with peeling, cracking, and minor bleeding may be related
571285 - to side effects of Omeprazole increasing dose from 20 to 80
571286 - mg per day, ref SDS 67 8Q5I, citing case study on 101010
571287 - 0744. ref SDS 48 11Y4
571289 - ..
571290 - [On 101219 1402 letter notifies medical team of rising
571291 - symptoms which may relate to Omeprazole, and requests
571292 - adjustments in dose, remedial measures. ref SDS 69 5N3O
571294 - ..
571295 - Discussed again entering work plans and prognosis into the medical
571296 - chart for release to the patient next week, scheduled with ROI
571297 - department on 101207 1152. ref SDS 62 DR7H Findings, planning, and
571298 - prognosis in the medical chart for work today facilitate doctor
571299 - patient partnership meeting with primary care scheduled 101223.
571300 -
571301 - [...below medical chart reports Doctor Lee's work plan to
571302 - continue treatment to relieve swallowing problem.
571303 - ref SDS 0 XT5N
571305 - ..
571306 - [On 101222 0800 ROI reported medical records cannot be
571307 - released to the patient because the record meeting with
571308 - Doctor Lee on 101210 for EGD procedure has not been entered
571309 - into the VA computer system for release to the patient.
571310 - ref SDS 70 Q15N
571312 - ..
571313 - [On 101222 0800 at 0833 Chris investigating progress in GI
571314 - Department completing transcription of progress notes into
571315 - the medical chart for meeting today on 101210. ref SDS 70
571316 - RR7N
571318 - ..
571319 - [On 110103 1314 Ray cannot find Progress Notes for meeting
571320 - at VA on 101210 for EGD in VA computer system; Kendal will
571321 - coordinate with Doctor Lee on completing the record.
571322 - ref SDS 72 QP8U
571324 - ..
571325 - [On 110107 1508 met with Ray at the Control Center for VA
571326 - GI Department in Martinez; Ray advised the doctor has not
571327 - had time to submit progress notes for meeting on 101210 to
571328 - perform EGD procedure; prepared handwritten letter to the
571329 - doctor reporting improved swallowing from excellent work on
571330 - 101210, and requested again the doctor's report on findings
571331 - with biopsy report; submitted copty to Wilma in ROI
571332 - Department. ref SDS 74 XL7K
571334 - ..
571335 - [On 110114 1309 received CD letter from Wilma transmitting
571336 - all requested medical records, including meeting with
571337 - Doctor Lee and lab on 101207, meeting with Doctor Lee for
571338 - EGD and biopsy on 101210, and meeting with Doctor Sandhu on
571339 - 101223. ref SDS 75 355H
571341 - ..
571342 - The discharge nurse advised that the VA computer system will not
571343 - accept scheduling the doctor for February. She asked the patient to
571344 - call the VA in January for schedule the follow up EGD test in
571345 - February.
571346 -
571347 - [On 101214 2330 received letter from VA dated today,
571348 - 101210, and scheduling the next EGD test on 110218 0730.
571349 - ref SDS 65 V294
571351 - ..
571352 - [On 101216 1021 letter commends medical team for excellent
571353 - work, and confirms schedule next EGD on 110218 0730.
571354 - ref SDS 66 K35G
571356 - ..
571357 - Overall, a very successful experiment, and big relief getting this
571358 - done, per above. ref SDS 0 6F7T
571359 -
571360 - [On 110107 0308 letter to VA commends Doctor Lee and
571361 - medical team for excellent work improving swallowing with
571362 - EGD and dilation. ref SDS 73 3P40
571363 -
571364 -
571365 -
571366 -
5714 -
SUBJECTS
Medical Chart VA EGD 6011 Dilation Recover Achalasia Swallowing Dysp
7603 -
760401 - ..
760402 - VA Medical Record Progress Notes Meeting for EGD Test
760403 - Endoscopy EGD 60111 Gastroenterology Procedure Note
760404 -
760405 - Follow up ref SDS 47 LB6J, ref SDS 39 RQ3K.
760406 -
760407 - VA Progress Notes were received 5 weeks after the work was performed
760408 - today, reported on 110114 1309. ref SDS 75 GT5K
760409 -
760410 - F:\05\00003\SM\CC\AGMJ\20101210-125523\welch0144.pdf
760412 - ..
760413 - LOCAL TITLE: EGD 60111
760414 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
760415 - DATE OF NOTE: DEC 10, 2010@09:30
760416 - ENTRY DATE: DEC 14, 2010@12:55:23
760417 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
760418 - URGENCY: STATUS: COMPLETED
760419 -
760420 - *** EGD 60111 Has ADDENDA ***
760426 - ..
760427 - 1. NAME OF PROCEDURE:
760428 -
760429 - 1. Esophagogastroduodenoscopy.
760430 - 2. TTS balloon dilation of esophageal stricture.
760431 - 3. Endoscopic biopsy.
760433 - ..
760434 - 2. ATTENDING PHYSICIAN: Randall E. Lee, M.D.
760436 - ..
760437 - 3. INDICATIONS:
760440 - ... is a 65-year-old man with history of acolasia. He
760441 - underwent laparoscopic myotomy with fundoplication at the San
760442 - Francisco VA December 2009. He has developed a distal
760443 - esophageal stricture between 38 and 40 cm believed to be due to
760444 - esophageal reflux. He had an EGD March and August of 2010 at
760445 - which time his esophageal stricture was dilated. Biopsies
760446 - continue to show no evidence of malignancy and no evidence of
760447 - Barrett's esophagus.
760449 - ..
760450 - 4. He was seen for follow up earlier this week at which time he
760451 - noted significant worsening of his dysphagia. This procedure
760452 - is undertaken for diagnostic and therapeutic purposes.
760454 - ..
760455 - 5. CONSENT: The risks, benefits, and alternatives to this procedure
760456 - including, but not limited to the risk of bleeding and bowel
760457 - perforation were explained to the patient. The patient understood
760458 - and provided written informed consent.
760460 - ..
760461 - 6. INTRAVENOUS MEDICATION:
760462 -
760463 - At the patient request, this procedure was performed without
760464 - any intravenous anesthesia.
760466 - ..
760467 - The patient did receive nebulized lidocaine as well as oral
760468 - viscous lidocaine.
760470 - ..
760471 - 7. PROCEDURE:
760472 -
760473 - In the Martinez VA GI Endoscopy Unit, the patient was placed in
760474 - the left lateral decubitus position. Oxygen at 2 liters per
760475 - minute by nasal canula was administered. Continuous oximetric
760476 - and hemodynamic monitoring was initiated.
760478 - ..
760479 - After a bite block was placed in the patient's mouth an Olympus
760480 - GIF Q180 video gastroscope was advanced under direct vision
760481 - into the esophagus. There was a small amount of retained
760482 - esophageal contents that easily irrigated and suctioned away.
760484 - ..
760485 - At approximately 39 cm to 40 cm was a distal esophageal
760486 - stricture with no evidence of mass effect. This did not yield
760487 - to gentle pressure of the endoscope. A Quantum TTS balloon was
760488 - advanced through the stricture and inflated sequentially to 12,
760489 - 13, and 14 mm.
760491 - ..
760492 - Achieving dilation to maximum of 14 mm today, appears slight
760493 - regression of prior work on 100827 0738, when Progress Notes seem to
760494 - report LESV was expanded with pneumatic (balloon) dilation from
760495 - initial contition to 12.9 then again to 14 and finally to 15 mm.
760496 - ref SDS 47 JE6X
760497 -
760498 - LESV Dilated
760499 - Date from to
760500 - 101210 11 14.................... ref SDS 0 H347
760501 - 100827 11 15.................... ref SDS 47 JE6X
760502 - 100305 11 15.................... ref SDS 39 WR6L
760504 - ..
760505 - [On 110218 0730 record of next EGD dilation indicates LESV
760506 - dilated 11 mm to 14 mm. ref SDS 77 AA5O
760508 - ..
760509 - Progress Notes for meeting on 101210 continue...
760510 -
760511 - The balloon was then removed and the endoscope was advanced
760512 - easily through the stricture and into the descending duodenum.
760514 - ..
760515 - Retroflexed views of the incisura, fundus, and cardia were
760516 - performed.
760518 - ..
760519 - Random biopsies were taken of the stomach labeled A, biopsies
760520 - taken from the esophageal stricture at about 40 cm labeled B,
760521 - and biopsies that were taken in the vicinity of a previously
760522 - tattooed site on the esophagus at 35 cm and labeled C. The
760523 - stomach and esophagus were decompressed and the gastroscope
760524 - removed.
760526 - ..
760527 - 8. COMPLICATIONS: None.
760529 - ..
760530 - 9. FINDINGS:
760531 -
760532 - 1. Previous site of plaque within the esophageal body noted by
760533 - prior tattoo although no evidence of mass effect
760534 - identified. This area was biopsied labeled C.
760535 -
760536 - 2. Atonic esophageal body.
760538 - ..
760539 - 3. Distal esophageal stricture with ulceration between
760540 - 39-40 cm.
760542 - ..
760543 - 4. Distorted fundus consistent with known fundoplication.
760545 - ..
760546 - 5. Mild gastric antral erythema without erosions or
760547 - ulceration.
760549 - ..
760550 - 6. Normal pylorus.
760552 - ..
760553 - 7. Normal duodenum to D2.
760555 - ..
760556 - 10. IMPRESSION:
760557 -
760558 - 1. Previously indentified esophageal plaque at 35 cm no longer
760559 - identified. This is most likely due to trauma from the
760560 - passage of dilators of the last EGD.
760562 - ..
760563 - 2. Current esophageal stricture with acid reflux stricture.
760564 - Repeat biopsies were again taken to determine the presence
760565 - or absence of malignancy; however the appearance of the
760566 - stricture does not support this diagnosis.
760568 - ..
760569 - Doctor does not attribute "acid reflux" esophageal stricture to
760570 - "inconsistent use of Omeprazole, reported in the medical chart for
760571 - prior EGD and dilation procedure on 100827 0738. ref SDS 47 JE9J
760572 - ref SDS 47 JE9J This change in the VA medical chart reflects case
760573 - study in the record on 101010 showing patient's consistent use of
760574 - Omeprazole, ref SDS 48 QJ5I, and cited in the letter to the VA on
760575 - 101206 1542. ref SDS 59 NP5G The next day, the doctor met with the
760576 - patient and reported there was not enough time for the medical team to
760577 - review patient history submitted with the letter on 101206; however,
760578 - during that same meeting at the VA the doctor took time to read the
760579 - letter and examine patient history on the patient's computer, reported
760580 - on 101207 1000. ref SDS 61 IR8G The doctor found consistent use of
760581 - Omeprazole, correcting prior impression in the medical chart for EGD
760582 - and dilation procedure on 100827 0738. ref SDS 47 JE9J As a result,
760583 - the medical chart today does not cite inconsistent use of Omeprazole
760584 - for continued severe esophageal stricture for causing recent increased
760585 - swallowing problems, also, reported in patient history from case study
760586 - on 101010 0744, ref SDS 48 V34I, and further reported in the letter to
760587 - the VA on 101206 1542, ref SDS 59 7Q8X, transmitting case study and
760588 - read by the doctor during the meeting on 101207 1000. ref SDS 61 IR8G
760590 - ..
760591 - VA medical chart for procedure on 101210 continues...
760592 -
760593 - 3. Gastritis mild and previously identified.
760595 - ..
760596 - 11. RECOMMENDATIONS:
760597 -
760598 - 1. Await the pathology results.
760599 -
760600 - [below, pathology report on biopsy supports findings
760601 - during EGD procedure. ref SDS 0 PTPU
760603 - ..
760604 - 2. Continue omeprazole, but boost to 40 mg twice a day 15
760605 - minutes before a meal.
760607 - ..
760608 - Increasing Omeprazole to 80 mg per day doubles medication, after
760609 - doubling the dose previously on 100827 0738, ref SDS 47 SG8M This
760610 - tries to prevent severe esophageal sphincter swallowing problems
760611 - discussed with the doctor, shown above, ref SDS 0 I94I, and reported
760612 - in findings, ref SDS 0 559H, and impression. ref SDS 0 UR5K
760613 -
760614 - [On 110429 1230 Discharge documents for EGD dilation
760615 - says to continue dose at 40 mg/day, ref SDS 78 6Q4F,
760616 - which seems conflicting with prescription today for 80
760617 - mg/day, per above. ref SDS 0 5I5H
760619 - ..
760620 - Original prescription for Omeprazole 20 mg, taking 1 pill per day,
760621 - reported on 100308 1411, ref SDS 40 CH3O, was not discussed after
760622 - first EGD and dilation procedure on 100305 1000. ref SDS 38 HB86
760623 - Medical chart for initial procedure only lists "Findings," and do not
760624 - present Impressions and Recommendations, as shown in the medical chart
760625 - today, per above. ref SDS 0 PWQS As a result, no prescription appears
760626 - in the medical chart for Omeprazole medication on 100305 1000.
760627 - ref SDS 38 Y65V
760629 - ..
760630 - VA medical chart Recommendations on 101210 continues...
760631 -
760632 - 3. Repeat EGD with dilation in approximately 2 months. The
760633 - eventual goal will be to dilate the distal esophagus to
760634 - approximately 16 or 17 mm.
760635 -
760636 - [...above, after EDG and dilation, Doctor Lee discussed
760637 - planning for next procedure to dilate esophagus to 17
760638 - mm. ref SDS 0 BF6L
760640 - ..
760641 - 12. DISPOSITION:
760642 -
760643 - 1. The patient was observed in the recovery room then
760644 - discharged to home.
760645 -
760646 - 2. I reviewed the endoscopic findings with the patient prior
760647 - to discharge.
760649 - ..
760650 - D: 12/10/2010
760651 - T: 12/13/2010
760652 - Job number: 67392
760653 - AFJ/CMTS
760654 - $end:
760656 - ..
760657 - /es/ RANDALL E LEE, MD
760658 - STAFF PHYSICIAN, GASTROENTEROLOGY
760659 - Signed: 01/07/2011 17:58
760660 -
760661 -
760662 -
7607 -
SUBJECTS
Biopsy Report Dated 101215 EGD Test VA 101210 Cancer Malignancy Not
A203 -
A20401 - ..
A20402 - Biopsy EGD Test Results Cancer Not Found
A20403 -
A20404 - Follow up ref SDS 47 PVXX.
A20405 -
A20406 - VA biopsy report was received 5 weeks after the work was performed
A20407 - today, reported on 110114 1309. ref SDS 75 GT5K
A20409 - ..
A20410 - 1. SURGICAL PATHOLOGY.................... ref DRP 1 PSUT
A20411 - Date Spec taken: Dec 10, 2010
A20412 - Date Spec rec'd: Dec 13, 2010 12:48
A20413 - Date completed: Dec 15, 2010
A20414 - Submitted by:
A20415 - Pathologist: JOAN BERNARD MD
A20416 - Resident: mahan MATIN MD
A20417 - Accession #: SP 10 9004
A20418 - Practitioner: RANDALL E LEE MD
A20420 - ..
A20421 - 2. Specimen:
A20422 -
A20423 - A. GASTRIC BX
A20424 - B. ESOPHAGEAL STRICTURE AT 40CM BX
A20425 - C. ESOPHAGUS AT 35CM BX
A20427 - ..
A20428 - 3. Brief Clinical History:
A20429 -
A20430 - 65 Y/O MAN WITH ACHALASIA & STRICTURE OF DISTAL ESOPHAGUS ?
A20431 - MALIGNANCY OR DYSPLASIA
A20433 - ..
A20434 - 4. Preoperative Diagnosis:
A20435 -
A20436 - ACHALASIA ?
A20438 - ..
A20439 - 5. Operative Findings:
A20440 -
A20441 - MILD GASTRIC ERYTHEMA ESOPHAGEAL STRICTURE ATONIC ESOPHAGEAL
A20442 - BODY
A20444 - ..
A20445 - 6. Postoperative Diagnosis:
A20446 -
A20447 - GASTRITIS GERD STRICTURE ACHALASIA
A20449 - ..
A20450 - 7. Gross description:
A20451 -
A20452 - A. The specimen is received in formalin designated "gastric
A20453 - biopsy" and consists of multiple fragments of tan tissue
A20454 - measuring 1.1 x 0.6 x 0.1cm in aggregate. Totally
A20455 - submitted in one cassette.
A20457 - ..
A20458 - B. The specimen is received in formalin designated "esophageal
A20459 - stricture at 40cm biopsy" and consists of multiple
A20460 - fragments of tan tissue measuring 0.8 x 0.5 x 0.1cm.
A20461 - Totally submitted in one cassette.
A20463 - ..
A20464 - C. The specimen is received in formalin designated "esophagus
A20465 - at 35cm biopsy" and consists of multiple fragments of tan
A20466 - tissue measuring 0.5 x 0.3 x 0.1cm in aggregate. Totally
A20467 - submitted in one cassette. (MM/12/13/10/men)
A20469 - ..
A20470 - 8. Microscopic exam/diagnosis: (Date Spec taken: Dec 10, 2010)
A20471 -
A20472 - A. STOMACH, GASTRIC (BIOPSY):
A20473 -
A20474 - 1. CHRONIC GASTRITIS
A20475 - 2. NO EVIDENCE OF HELICOBACTER PYLORI IS SEEN WITH WARTHIN-STARRY STAIN
A20476 - 3. NO INTESTINAL METAPLASIA
A20478 - ..
A20479 - B. ESOPHAGUS AT 40CM (BIOPSY):
A20480 -
A20481 - 1. REFLUX ESOPHAGITIS, SEE COMMENT
A20482 - 2. NO INTESTINAL METAPLASIA (NO BARRETT'S ESOPHAGUS)
A20483 - 3. NO DYSPLASIA IDENTIFIED
A20485 - ..
A20486 - C. ESOPHAGUS AT 35CM (BIOPSY):
A20487 -
A20488 - 1. REFLUX ESOPHAGITIS, SEE COMMENT
A20489 - 2. NO INTESTINAL METAPLASIA (NO BARRETT'S ESOPHAGUS)
A20490 - 3. NO DYSPLASIA IDENTIFIED
A20492 - ..
A20493 - 9. COMMENTS:
A20494 -
A20495 - 1. If a clinically concerning lesion persists, then additional
A20496 - biopsy is recommended if clinically feasible.
A20498 - ..
A20499 - 2. This case was processed and examined at the Department of
A20500 - Veterans Affairs, Sacramento Medical Center, 10535 Hospital
A20501 - Way, Mather, CA 95655-1200.
A20502 -
A20503 -
A20504 -
A20505 -
A20506 -
A20507 -
A20508 -
A20509 -
A20510 -
A20511 -
A206 -