CONTACTS
SUBJECTS
VA EGD Procedure Dilate Stricture Lower Esophageal Sphincter Valve L
3903 -
3903 - ..
3904 - Summary/Objective
3905 -
390501 - Follow up ref SDS 65 0000. ref SDS 63 0000.
390502 -
390503 -
390504 -
390506 - ..
3906 -
3907 -
3908 - Background
3909 -
390901 - On 101210 EGD procedure dilated esophageal sphincter valve from 11 to
390902 - 14 mm. EGD today dilate from 14 to 17 mm. ref SDS 63 BF6L
390904 - ..
390905 - Test today was schedule in VA's letter dated 101210, received on
390906 - 101214 2330. ref SDS 65 ZG7O
390908 - ..
390909 - On 101216 1021 letter commends medical team for excellent work, and
390910 - confirms schedule next EGD on 110218 0730. ref SDS 66 K35G
390911 -
390913 - ..
3910 -
3911 -
3912 - Progress
3913 -
391301 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
391302 - GI Department VA Sacramento Medical Center Administration EGD Dilation
391303 -
391304 - Follow up ref SDS 63 KJ5N.
391305 -
391306 - Kathy drove from Sacramento and provided transportation to VA required
391307 - to perform EGD and dilation procedure with anesthesia, planned on
391308 - 110203 1130. ref SDS 69 MY8F The weather has been very good for
391309 - February, but the past 2 days has turned severe. Called Kathy last
391310 - night and offered to do the EGD today without sedation, so she does
391311 - not have to make the drive from Sacamento and back in bad weather.
391312 - Kathy was sure the drive would be okay, so wonderful she can be here
391313 - today.
391315 - ..
391316 - [On 110218 1948 letter from Kathy reporting safe return
391317 - home to Sacramento after VA medical procedure today, and
391318 - being designated driver, ref SDS 71 S59M; very kind and
391319 - levely saying glad to do it. ref SDS 71 P344
391321 - ..
391322 - [On 110220 2338 letter thanks Kathy for all her efforts
391323 - that helped with VA EGD and dilation procedure. ref SDS 72
391324 - SF9Y
391326 - ..
391327 - Checked in at 0730.
391329 - ..
391330 - Prepared patient history questionaire for the procedure.
391332 - ..
391333 - Submitted Kathy's cell phone for designated driver.
391334 -
391336 - ..
3914 -
3915 -
3916 - 0810
3917 -
391701 - Iris called patient into pre-op, took vitals, and set a catheter for
391702 - injecting anesthesthetic for conscious sedation. A second nurse
391703 - actually set the IV while Iris entered patient history for the record
391704 - on this procedure today.
391706 - ..
391707 - IV successful on first puncture, repeating Kendall's success for prior
391708 - EGD on 100827 0738. ref SDS 46 PR5P
391710 - ..
391711 - Explained error in Medical Chart saying patient does not have Advance
391712 - Directive on file with VA, reported on 100305 1000. ref SDS 39 MV6M
391714 - ..
391715 - Iris said the AD on file with VA Medical Center in San Francisco,
391716 - submitted on 091023 0445, ref SDS 14 WO5Y, is not available to the VA
391717 - Clinic in Martinez, even though the system is computerized.
391719 - ..
391720 - Iris requested a copy of patient's filing so the Martinez VA can make
391721 - a copy.
391723 - ..
391724 - Explained AD was received on a computer file received from the VA on
391725 - 100928 0706. ref SDS 48 PQ5R
391726 -
391727 -
391729 - ..
3918 -
3919 -
3920 - 0845
3921 -
392101 - Swallowing Degraded After Prior EGD Dilation Increased Vomitting
392102 - Vomitting Increased Swallowing Degraded After Prior EGD Dilation
392103 - Dilate LESV 14 MM and Double Omeprazole 80 MG to Improve Swallowing
392104 - Triamcinolone Steriod Omeprazole 40 MG Dilate LESV 14 MM Improve Swallowing
392105 -
392106 - Follow up ref SDS 63 I94I.
392107 -
392108 - Doctor Lee arrives. Signed consent for EGD and dilation procedure.
392110 - ..
392111 - Reported improved swallowing after EGD dilation on 101210, of lower
392112 - esophageal valve (LESV) from 11 to 14 mm, and doubling prescription
392113 - for Omeprazole from 40 to 80 mg per day. ref SDS 63 BF6L However,
392114 - improvement soon degraded causing severe difficulty swallowing,
392115 - evident from reports of continual vomitting in case study on 101010
392116 - 0744. ref SDS 49 X85F
392117 -
392118 - LESV Dilated
392119 - Date from to
392120 - 110218 11 14 w triamcinolone.... ref SDS 0 AA5O
392121 - 101210 11 14.................... ref SDS 63 H347
392122 - 100827 11 15.................... ref SDS 47 JE6X
392123 - 100305 11 15.................... ref SDS 39 WR6L
392125 - ..
392126 - Doctor Lee said he will try to improve swallowing that will relieve
392127 - vomitting problems by adding an injection of a steriod during the
392128 - procedure today.
392130 - ..
392131 - Previously, research on 051202, found that...
392132 -
392133 - Injection of botulinum toxin (botox) into the lower esophageal
392134 - sphincter (LES) can lead to improvement in symptoms with
392135 - reduced risk of complications. ref SDS 1 FV4M
392137 - ..
392138 - Today, the doctor did not describe the steriod planned for injection
392139 - to resist contraction of LESV.
392141 - ..
392142 - [...below, on 110218 0730 medical chart progress notes
392143 - Doctor Lee Procedure Note reports patient swallowing
392144 - improved since EGD and dilation on 101210. ref SDS 0 PQSS
392146 - ..
392147 - [...below on 110218 0730 Progress Notes report About 2 mL
392148 - of triamcinolone acetate 40 mg/mL were injected into the
392149 - esophageal stricture site. ref SDS 0 A296
392151 - ..
392152 - [On 110429 1230 during meeting for next EGD dilation
392153 - reported significantly improved swallowing and reduced
392154 - vomitting, following the doctor added triamcinolone steriod
392155 - injection to LESV to protocol today. ref SDS 76 FE3F
392157 - ..
392158 - [On 110429 1230 doctor indicated EGD examination found less
392159 - contraction; continued practice injecting steriod to avoid
392160 - contraction of LESF that aids swallowing and avoids
392161 - vomitting. ref SDS 75 SS5N
392163 - ..
392164 - [On 110429 1230 after EGD dilation procedure the doctor
392165 - advised that he added triamcinolone injection again today
392166 - in order to restrict contraction of LESV, and in order to
392167 - aid swallowing and reduce vomitting. ref SDS 76 SS5N
392169 - ..
392170 - [On 110819 0830 doctor reports in Progress Notes Impression
392171 - that improved swallowing (dysphagia) to reduce vomitting
392172 - attributed to avoiding contraction of LESV accomplished
392173 - with combination of Omeprazole, dilation and triamcinolone
392174 - steriod injections. ref SDS 78 QRXQ
392176 - ..
392177 - [On 111115 1300 doctor Impressions in Progress Notes for
392178 - next procedure report that adding triamcinolone steriod
392179 - injection to resist contraction of LESV was effective to
392180 - avoid severe swallowing and vomitting problems,
392181 - ref SDS 79 AW6J; yet, for some reason not presented in
392182 - the record triamcinolone injection was not performed on
392183 - 111115. ref SDS 79 IS6L
392185 - ..
392186 - [On 130416 1100 CT test shows remarkable recovery from
392187 - achalasia, Doctor Lee attributes favorable results reflects
392188 - combination therapy with Heller Myotomy surgery performed
392189 - by Doctor Stewart at VA Medical Center in San Francisco on
392190 - 091216, and subsequent persistent EGD dilation protocols
392191 - every 3 months together with Omeprazole medication, and
392192 - then a year later enhanced albeing intermittantly with
392193 - triamcinolone steriod injections to resist contractions of
392194 - LESV that aid swallowing and so avoid ballooning effect of
392195 - esophagus. ref SDS 80 E23K
392196 -
392198 - ..
392199 - Explained reduced side effects from high dose Omeprazole ordered on
392200 - 101210 0930. ref SDS 63 ZN4M Advised that severe skin dryness of face
392201 - and feet, including bleeding feet has declined, previously reported to
392202 - the VA on 101219 1402. ref SDS 67 BE9T Still seem very tired taking
392203 - 80 mg Omeprazole per day.
392205 - ..
392206 - Discussed reducing Omeprazole back to 40 mg per day if examination
392207 - today during EGD shows reduced acid burn from esophagitis.
392208 -
392209 - [...below, on 110218 0730 Discharge reports progress notes
392210 - show findings no acid burn inflection. ref SDS 0 MM43
392212 - ..
392213 - [...below, on 110218 0730 medical chart reports
392214 - recommendations to continue high dose Omeprazole 80 mg per
392215 - day, despite report of reduced acid burn. ref SDS 0 U59M
392216 -
392217 -
392219 - ..
3923 -
3924 -
3925 - 0910
3926 -
392601 - Walked into the OR. Iris was assisted by Lucia (not sure of name).
392602 -
392603 - Swallowed and gargled Lidocaine to numb the throat, standard
392604 - procedure, reported on 101210 0930. ref SDS 63 PL5O
392606 - ..
392607 - Iris gave Fentanyl, and then other drugs for conscious sedation, used
392608 - for anesthetic, reported in medical chart for procedure on 100827
392609 - 0738. ref SDS 46 JE9V
392610 -
392612 - ..
3927 -
3928 -
3929 - 1043
3930 -
393001 - Meeting Doctor Lee Review Preliminary Findings
393002 - VA Discharge Documentation Received
393003 -
393004 - Awake in recovery.
393005 -
393006 - This was a much better experience than the last procedure when
393007 - anesthesia was not used, reported on 101210 0930. ref SDS 63 BF6N
393009 - ..
393010 - Iris removed IV catheter. She called Kathy on the cell phone.
393012 - ..
393013 - Dressed and met with Doctor Lee.
393015 - ..
393016 - Doctor Lee explained findings and work plan noted in Discharge
393017 - Documentation...
393018 -
393019 - 1. Esophagitis scar formation found during procedure.
393020 -
393021 - 2. No acid burn infection in the reflux stricture (lower
393022 - esophageal sphincter valve VESV) observed during the EGD
393023 - procedure today.
393025 - ..
393026 - Unclear how this correlates with finding esophagitis, since
393027 - the record seems to indicate these are the same thing,
393028 - i.e., that esophagitis is a formal term for "acid burn."
393029 -
393030 - [...below on 110218 0730 medical chart Progress Notes do
393031 - not show finding no acid burn. ref SDS 0 U58H
393033 - ..
393034 - 3. Lower esophugeal sphinchter valve LESV (reflux stricture)
393035 - contracted back to about 11 mm, the same condition at the
393036 - time of prior procedure 3 months ago on 101210. Therefore,
393037 - today, repeated dilation expanding the sphincter again from
393038 - 11 mm to 14 mm, and so did not achieve objective to dilate
393039 - from 14 to 17 mm, set on 101210 0930. ref SDS 63 BF6L
393040 -
393041 - LESV Dilated
393042 - Date from to
393043 - 110218 11 14 w triamcinolone.... ref SDS 0 AA5O
393044 - 101210 11 14.................... ref SDS 63 H347
393045 - 100827 11 15.................... ref SDS 47 JE6X
393046 - 100305 11 15.................... ref SDS 39 WR6L
393048 - ..
393049 - 4. Steriod injected into the sphincter to help prevent
393050 - contraction from 14 mm dilated today back to 11 mm, as
393051 - occurred the past 4 months.
393053 - ..
393054 - This aligns with work plan discussed during the meeting earlier this
393055 - morning, per above. ref SDS 0 SR4G
393056 -
393057 - [...below on 110218 0730 Progress Notes report About 2
393058 - mL of triamcinolone acetate 40 mg/mL were injected into
393059 - the esophageal stricture site. ref SDS 0 A296
393061 - ..
393062 - [On 110429 1230 doctor indicated EGD examination found
393063 - less contraction; continued practice injecting steriod
393064 - to avoid contraction. ref SDS 75 SS5N
393066 - ..
393067 - [On 111115 1300 doctor Impressions in Progress Notes for
393068 - next procedure report that adding triamcinolone steriod
393069 - injection to resist contraction of LESV was effective to
393070 - avoid severe swallowing and vomitting problems,
393071 - ref SDS 79 AW6J; yet, for some reason not presented in
393072 - the record triamcinolone injection was not performed on
393073 - 111115. ref SDS 79 6H3N
393075 - ..
393076 - 5. Omeprazole dose held at 80 mg per day despite finding "no
393077 - acid burn in reflux stricture, evidently because of seeming
393078 - conflicting finding of esophagitis, per finding #1 above.
393079 - ref SDS 0 MM43
393081 - ..
393082 - 6. EGD dilation procedure scheduled 110429 1230
393084 - ..
393085 - The doctor did not provide photographs taken during the procedure, nor
393086 - explain changes in condition shown by new image evidence, contrary to
393087 - prior practice, reported on 101210 0930. ref SDS 63 XG6J
393088 -
393089 - [On 110218 1919 well wishes from Patty; mom and Rob also
393090 - called. ref SDS 70 GU5G
393092 - ..
393093 - [On 110304 2105 notified Peggy of findings. ref SDS 74 QW8P
393095 - ..
393096 - Was somewhat groggy when Doctor Lee consulted after the procedure in
393097 - the recovery room. He was hurried to care for another patient, so
393098 - there was not enough time to get photographs today. Therefore need
393099 - photographs to be included with medical chart.
393100 -
393102 - ..
3932 -
3933 -
3934 - 1112
3935 -
393501 - Received discharge document for EGD procecure. Hnadwritten notes are
393502 - difficult to read, but seem to align with Doctor Lee's report per
393503 - above. ref SDS 0 MM43
393505 - ..
393506 - Kathy arrived. She had breakfast at Carrows across the street, then
393507 - slept in the car until getting the call from Iris.
393509 - ..
393510 - Discharged.
393512 - ..
393513 - Kathy and I walked down to ROI (Release of Information) Department on
393514 - the 2nd floor and met with Wilma. Filled out form requesting medical
393515 - chart for the work today.
393516 -
393517 - [On 110218 1948 letter from Kathy reporting safe return
393518 - home to Sacramento after VA medical procedure today, and
393519 - being designated driver, ref SDS 71 S59M; very kind and
393520 - levely saying glad to do it. ref SDS 71 P344
393522 - ..
393523 - [On 110220 2338 letter thanks Kathy for all her efforts
393524 - that helped with VA EGD and dilation procedure. ref SDS 72
393525 - SF9Y
393526 -
393527 -
393528 -
3936 -
SUBJECTS
Medical Chart Progress Notes VA EGD 6011 Dilate 11 to 14 MM Recover
6503 -
650401 - ..
650402 - VA Medical Record Progress Notes Meeting for EGD Test
650403 - Endoscopy EGD 60111 Gastroenterology Procedure Note
650404 -
650405 - Follow up ref SDS 63 JT7N, ref SDS 47 LB6J.
650406 -
650407 - VA medical chart with Progress Notes was received 2 weeks after work
650408 - was performed today, reported on 110304 1126, ref SDS 73 NX5I
650409 -
650410 - F:\05\00003\SM\CC\AGMJ\20110218-073019\welch-0144.pdf
650412 - ..
650413 - LOCAL TITLE: EGD 60111......................... ref DRP 1 0212
650414 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
650415 - DATE OF NOTE.................. FEB 18, 2011@07:30
650416 - ENTRY DATE.................... FEB 23, 2011@10:43:19
650417 - ATTENDING PHYSICIAN........... Randall E. Lee, M.D.
650418 - AUTHOR........................ LEE,RANDALL E EXP COSIGNER:
650419 - URGENCY....................... STATUS: COMPLETED
650420 - *** EGD 60111 Has ADDENDA ***
650421 - PATIENT NAME.................. WELCH, RODNEY CHARLES
650422 - DATE OF BIRTH................. 03/01/1945
650424 - ..
650425 - 1. NAME OF PROCEDURES:
650426 -
650427 - 1. Esophagogastroduodenoscopy.
650428 - 2. Endoscopic biopsy.
650429 - 3. TTS balloon dilation of esophageal stricture.
650431 - ..
650432 - 2. INDICATIONS:
650433 -
650435 - achalasia [...diagnosed following EGD procedure by Doctor Lee
650436 - at VA on 051209 1130. ref SDS 2 5B5K...] He underwent
650437 - laparoscopic myotomy with fundoplication at the San Francisco
650438 - VA December 2009 [...Doctor Stewart performed Heller Myotomy
650439 - surgery at San Francisco Medical Center on 091216 0600.
650440 - ref SDS 28 KE9U...] He developed a distal esophageal stricture
650441 - believed to be due to esophageal reflux. [...diagnosed as "Acid
650442 - Burn" by Doctor Lee on 100305 1000. ref SDS 39 PR6P EGDs
650443 - March, August, and December 2010 showed recurrent stricture in
650444 - between dilations. [...see medical chart findings on 101210
650445 - 0930. ref SDS 63 559H...] Biopsies show no evidence of
650446 - malignancy and no evidence of Barrett's esophagus. [...see
650447 - biopsy on 101210 0930. ref SDS 63 PTPU, and pathology report
650448 - for biopsies taken today, listed below, ref SDS 0 PPYS...]
650449 - Since his last dilation December he noted marked improvement in
650450 - his dysphagia grade [...i.e., reduced difficulty swallowing...]
650451 - and says that he was able to swallow small pieces of meat.
650452 - This procedure is now undertaken for treatment.
650454 - ..
650455 - Doctor Lee's report of "improvement" in dysphagia (swallowing
650456 - difficulties) in the medical chart Progress Notes for EGD and dilation
650457 - conflicts with discussion prior to the procedure today, and reporting
650458 - that swallowing degraded, shown by case study reporting continual
650459 - vomitting since the prior procedure on 101210, per above, ref SDS 0
650460 - SR4G
650462 - ..
650463 - Medical chart does not report patient history of severe side effects
650464 - from doubling dose of Omeprazole, reported to the medical team
650465 - beginning on 101218 in case study on 101010 0744. ref SDS 49 11Y4; VA
650466 - was notified the next day in a letter on 101219 1402. ref SDS 67 BE9T
650467 - During the meeting today, notified the doctor that side effects have
650468 - recently subsided, perhaps indicating the body has acclimated to
650469 - increased dose of Omeprazole, per above. ref SDS 0 SR5N
650471 - ..
650472 - Medical Chart Progress Notes continue...
650473 -
650474 - 3. CONSENT:
650476 - ..
650477 - The risks, benefits, and alternatives to this procedure including,
650478 - but not limited to, the risks of bleeding and bowel perforation, were
650479 - explained to the patient. The patient understood and provided
650480 - written informed consent.
650482 - ..
650483 - 4. INTRAVENOUS MEDICATIONS:
650484 -
650485 - 1. Diphenhydramine 50 mg.
650486 - 2. Fentanyl 150 mcg.
650487 - 3. Midazolam 4 mg.
650489 - ..
650490 - 5. PROCEDURE:
650492 - ..
650493 - In the Martinez VA GI Endoscopy Unit, the patient was
650494 - placed in the left lateral decubitus position.
650496 - ..
650497 - Oxygen at 2 liters per minute by nasal canula was administered.
650499 - ..
650500 - Continuous oximetric and hemodynamic monitoring was initiated.
650502 - ..
650503 - After a bite block was placed in the patient's mouth an Olympus
650504 - GIFH180 video gastroscope was advanced under direct vision into
650505 - the descending esophagus.
650507 - ..
650508 - There was a small amount of retained saliva within the
650509 - esophagus that was easily irrigated and suctioned away.
650511 - ..
650512 - Areas of the esophageal mucosa were covered with a thin film of
650513 - residue, which was biopsied and labeled B.
650515 - ..
650516 - At approximately 39 cm was a distal esophageal stricture
650517 - without evidence of asymmetric mass effect. This did not yield
650518 - to gentle pressure of the endoscope. At 34 cm, approximately 1
650519 - cm cephalad to a previous placed tattoo site was a slightly
650520 - depressed esophageal plaque of about 1 cm in overall diameter.
650521 - This was biopsied and labeled specimen A.
650523 - ..
650524 - Subsequently, a TTS balloon was advanced through the stricture
650525 - and inflated sequentially to 12, 13, and 14 mm. The balloon
650526 - was removed and the endoscope advanced easily through the
650527 - stricture and into the descending duodenum.
650528 -
650529 - LESV Dilated
650530 - Date from to
650531 - 110218 11 14 w triamcinolone.... ref SDS 0 AA5O
650532 - 101210 11 14.................... ref SDS 63 H347
650533 - 100827 11 15.................... ref SDS 47 JE6X
650534 - 100305 11 15.................... ref SDS 39 WR6L
650536 - ..
650537 - [On 110429 1230 at 1613 record of next EGD dilation
650538 - indicates LESV dilated to 16.5 mm, ref SDS 76 U23I
650540 - ..
650541 - Medical Chart Progress Notes continue...
650542 -
650543 - Retroflexed views of incisura, fundus, and cardia were
650544 - performed.
650546 - ..
650547 - About 2 mL of triamcinolone acetate 40 mg/mL were injected into
650548 - the esophageal stricture site.
650550 - ..
650551 - This aligns with the doctor's new work plan today for maintaining
650552 - dilation of LESV with injection of steriod in order to aid swallowing
650553 - and prevent vomitting, discussed prior to the procedure, per above.
650554 - ref SDS 0 SR4G
650555 -
650556 - LESV Dilated
650557 - Date from to
650558 - 110218 11 14 w triamcinolone.... ref SDS 0 AA5O
650559 - 101210 11 14.................... ref SDS 63 H347
650560 - 100827 11 15.................... ref SDS 47 JE6X
650561 - 100305 11 15.................... ref SDS 39 WR6L
650563 - ..
650564 - Previously, research on 051202, found 3 primary treatments for
650565 - achalasia are balloon dilation, which is the current protocol; and
650566 - Heller myotomy surgery, which was performed on 091216 0600,
650567 - ref SDS 28 KE9U, and the following, listed in research on 051202
650568 - saying in part...
650569 -
650570 - Injection of botulinum toxin (botox) into the lower esophageal
650571 - sphincter (LES) can lead to improvement in symptoms with
650572 - reduced risk of complications. ref SDS 1 FV4M
650574 - ..
650575 - Subsequent research on 140720, does not find comparison of botulinum
650576 - with triamcinolone. Following study indicates triamcinolone steriod
650577 - works better than botulinum toxin to treat tennis elbow, shown on the
650578 - Internet...
650579 -
650580 - Pubmed.gov
650582 - ..
650583 - Comparison between botulinum toxin and corticosteroid
650584 - injection in the treatment of acute and subacute tennis
650585 - elbow: a prospective, randomized, double-blind, active
650586 - drug-controlled pilot study.
650587 -
650588 - http://www.ncbi.nlm.nih.gov/pubmed/20134306
650590 - ..
650591 - Abstract
650592 - OBJECTIVE:
650593 - To compare botulinum toxin type A injection with
650594 - corticosteroid injection in the treatment of tennis elbow.
650596 - ..
650597 - DESIGN: In this prospective, randomized, double-blind,
650598 - drug-controlled trial,19 affected elbows of 16 patients
650599 - were randomly assigned to receive injection with botulinum
650600 - toxin type A (Botox group) or triamcinolone acetonide
650601 - (steroid group). We used the Visual Analog Scale,
650602 - pain-free grip strength, and World Health Organization
650603 - Quality of Life Brief Questionnaire to assess the
650604 - perception of pain, grip strength, and quality of life,
650605 - respectively. Measures were performed before and at 4, 8,
650606 - and 12 wks after the treatment.
650608 - ..
650609 - Four weeks after the treatment, the Botox group had
650610 - smaller decrease in pain (P = 0.02) but greater decrease
650611 - in grip strength (P = 0.01). The difference in grip
650612 - strength remained significant at 8 wks (P = 0.03). No
650613 - significant differences in quality of life were observed
650614 - throughout the study period.
650616 - ..
650617 - CONCLUSIONS:
650618 - Corticosteroid is superior to botulinum toxin type A in
650619 - relieving pain in tennis elbow at 4 wks after injection.
650620 - Because botulinum toxin injection did not relieve pain
650621 - significantly but is associated with weakness, the muscle
650622 - weakness caused by botulinum toxin is unlikely to be the
650623 - sole mechanism of the pain relief observed in previous
650624 - studies.
650626 - ..
650627 - Whether better results that occur treating tennis elbow with
650628 - triamcinolone steriod compared to botulinum toxin translates well to
650629 - achalasia is not clear in the record.
650631 - ..
650632 - There may be a concern that side effects of steriods might be higher
650633 - medical risk than toxin.
650635 - ..
650636 - Since this treatment only occurs every 4 months or so, the risk might
650637 - be minimal.
650639 - ..
650640 - [On 110429 1230 during meeting for next EGD dilation
650641 - reported significantly improved swallowing and reduced
650642 - vomitting, following the doctor added triamcinolone steriod
650643 - injection to LESV to protocol today. ref SDS 76 FE3F
650645 - ..
650646 - [On 110429 1230 doctor indicated EGD examination found less
650647 - contraction; continued practice injecting steriod to avoid
650648 - contraction of LESF that aids swallowing and avoids
650649 - vomitting. ref SDS 75 SS5N
650651 - ..
650652 - [On 111115 1300 doctor Impressions in Progress Notes for
650653 - next procedure report that adding triamcinolone steriod
650654 - injection to resist contraction of LESV was effective to
650655 - avoid severe swallowing and vomitting problems,
650656 - ref SDS 79 AW6J; yet, for some reason not presented in
650657 - the record triamcinolone injection was not performed on
650658 - 111115. ref SDS 79 6H3N
650660 - ..
650661 - Medical Chart Progress Notes continue...
650662 -
650663 - The stomach was decompressed and the gastroscope then removed.
650665 - ..
650666 - Complications none.
650668 - ..
650669 - The patient tolerated the procedure well.
650671 - ..
650672 - FINDINGS:
650673 -
650674 - 1. Esophageal plaque at about 34 cm biopsied. The edges were
650675 - not raised, but this area appeared to be slightly
650676 - depressed.
650678 - ..
650679 - Discharge documentation and post-procedure discussion with the doctor
650680 - reported finding no evidence of acid burn, per above. ref SDS 0 MM43
650682 - ..
650683 - Medical Chart Progress Notes continue...
650684 -
650685 - 2. Esophageal stricture at 39 cm without evidence of
650686 - malignancy.
650688 - ..
650689 - 3. Atonic esophageal body.
650691 - ..
650692 - 4. Distorted fundus consistent with known fundoplication.
650694 - ..
650695 - 5. Normal gastric mucosa.
650696 - 6. Normal pylorus.
650697 - 7. Normal duodenum to D2.
650699 - ..
650700 - IMPRESSION:
650701 -
650702 - 1. Esophageal plaque at 34 cm again noted. This was biopsied
650703 - to determine the presence or absence of dysplasia.
650704 -
650705 - 2. Recurrent esophageal stricture consistent with acid reflux
650706 - stricture. Triamcinolone acetate was injected to retard
650707 - the reformation of the stricture.
650709 - ..
650710 - Discharge documentation and post-procedure discussion with the doctor
650711 - reported finding no evidence of acid burn, per above. ref SDS 0 MM43
650712 -
650713 - [On 110429 1230 doctor indicated EGD examination found
650714 - less contraction; continued practice injecting steriod
650715 - to avoid contraction. ref SDS 75 SS5N
650717 - ..
650718 - Medical Chart Progress Notes continue...
650720 - ..
650721 - 3. Atonic esophageal body consistent with known diagnosis of
650722 - achalasia.
650724 - ..
650725 - RECOMMENDATIONS:
650726 -
650727 - 1. Await the pathology results.
650729 - ..
650730 - 2. Continue omeprazole 40 mg twice a day 15 minutes before a
650731 - meal without reduction.
650733 - ..
650734 - Prior to procedure today, discussed reducing Omeprazole to reduce side
650735 - effects if EGD examination finds reduced acid bure, per above.
650736 - ref SDS 0 SR64
650738 - ..
650739 - Medical Chart Progress Notes continue...
650740 -
650741 - 3. Repeat EGD with dilation in approximately in 2 months.
650743 - ..
650744 - DISPOSITION:
650745 -
650746 - 1. The patient was observed in the Recovery Room then
650747 - discharged to home with a companion.
650748 -
650749 - 2. I reviewed the endoscopic findings with the patient prior
650750 - to discharge.
650752 - ..
650753 - 3. At the patient's convenience he may choose to have some or
650754 - all of his next endoscopic evaluations at the Sacramento VA
650755 - due to the closer proximity to the patient's sister.
650767 - ..
650768 - 02/25/2011 ADDENDUM STATUS: UNSIGNED
650769 - You may not VIEW this UNSIGNED Addendum.
650770 -
650771 -
650772 -
650773 -
650774 -
6508 -
SUBJECTS
Biopsy Report Dated 110224 EGD Test VA 110218 Cancer Malignancy Not
9603 -
960401 - ..
960402 - Biopsy EGD Test Results Cancer Not Found
960403 -
960404 - Follow up ref SDS 63 PWVT, ref SDS 47 PVXX.
960405 -
960406 - VA biopsy report was received 2 weeks after work was performed today,
960407 - reported on 110304 1126, ref SDS 73 NX5I
960409 - ..
960410 - 1. SURGICAL PATHOLOGY ---............... ref DRP 1 PPTX
960411 - Date Spec taken: Feb 18, 2011 Pathologist:IVAN D MEADOWS MD
960412 - Date Spec rec'd: Feb 22, 2011 10:49 Resident:
960413 - Date completed: Feb 24, 2011 Accession #: SP 11 1314
960414 - Submitted by: Practitioner:RANDALL E LEE MD
960416 - ..
960417 - 2. Specimen:
960418 -
960419 - A. ESOPHAGEAL PLAQUE AT 34CM BX
960420 - B. RANDOM ESOPHAGUS BX'S
960422 - ..
960423 - 3. Brief Clinical History:
960424 -
960425 - (NO CLINICAL HISTORY GIVEN)
960427 - ..
960428 - 4. Preoperative Diagnosis:
960429 -
960430 - HX ACHALASIA & ESOPHAGEAL STRICTURE
960432 - ..
960433 - 5. Operative Findings:
960434 -
960435 - EGD
960437 - ..
960438 - 6. Postoperative Diagnosis:
960439 -
960440 - DEPRESSED PLAQUE AT 34CM
960442 - ..
960443 - 7. Gross description:
960444 -
960445 - A. The specimen is received in formalin designated "esophageal
960446 - biopsy at 34cm" and consists of multiple irregular
960447 - fragments of tan-yellow soft tissue measuring in aggregate
960448 - 0.9 x 0.9 x 0.3cm. Totally submitted in one cassette.
960450 - ..
960451 - B. The specimen is received in formalin designated "esophagus
960452 - biopsy" and consists of multiple irregular fragments of
960453 - tan-white soft tissue measuring in aggregate 1.1 x 0.8 x
960454 - 0.3cm. Totally submitted in one cassette. (RS/2/22/11/men)
960456 - ..
960457 - 8. Microscopic exam/diagnosis: (Date Spec taken: Feb 18, 2011)
960458 -
960459 - A. ESOPHAGUS AT 34CM (BIOPSY): SQUAMOUS MUCOSA WITH
960460 - SUPERFICIAL SEVERE ACUTE INFLAMMATION
960462 - ..
960463 - B. ESOPHAGUS, RANDOM (BIOPSY):
960464 -
960465 - -SQUAMOUS MUCOSA WITH ACUTE INFLAMMATION
960466 - -PAS-F STAIN IS POSITIVE FOR FUNGAL ORGANISMS
960468 - ..
960469 - Absence of diagnosis indicates no findings of cancer (malignancy).
960471 - ..
960472 - This diagnosis seems vague, but "fungal organisms" is associated with
960473 - esophagitis in literature on the the Internet...
960474 -
960475 - Bookshelf
960476 - US National Library of Medicine
960477 - National Institute of Health
960478 -
960479 - http://www.ncbi.nlm.nih.gov/books/NBK12725/
960481 - ..
960482 - Esophagitis
960484 - ..
960485 - In addition to mucositis, esophageal injury and infection are
960486 - frequently recognized in patients undergoing cancer treatment
960487 - and in the immunocompromised host. Esophagitis can be caused
960488 - by cytotoxic chemotherapy and irradiation, as well as by
960489 - viral, bacterial, and fungal organisms.
960491 - ..
960492 - Biopsy pathology report concludes...
960493 -
960494 - 9. This case was processed and examined at the Department of
960495 - Veterans Affairs, Sacramento Medical Center, 10535 Hospital
960496 - Way, Mather, CA 95655-1200.
960497 -
960498 -
960499 -
960500 -
960501 -
960502 -
960503 -
960504 -
9606 -