CONTACTS
SUBJECTS
VA EGD Procedure Dilate Stricture Lower Esophageal Sphincter Valve L
2803 -
2803 - ..
2804 - Summary/Objective
2805 -
280501 - Follow up ref SDS 72 0000. ref SDS 68 0000.
280502 -
280503 - Good news today EDG finding reduced esophagitis infection, ref SDS 0
280504 - MM43, and dilating esophageal stricture in LESV to the size of "ring
280505 - finger," which appears to exceed objectives, and so shows progress
280506 - recovering from swallowing problems collateral to achalasia.
280507 - ref SDS 0 SS5R VA has been persistent and effective treating chronic
280508 - swallowing problems. Considered review at VA San Francisco Medical
280509 - Center Surgery Department for correlation with objectives on Heller
280510 - Myotomy surgery in December 2009, and prospects for refinements to
280511 - advance recovery in the current case, ref SDS 0 QF6L, and for future
280512 - patients. ref SDS 0 HO5H Difficulty accessing relevant patient
280513 - history using VA computer at the clinic in Martinez, aligns with
280514 - problems experienced at the VA Medical Center in San Francisco.
280515 - ref SDS 0 EK5J Difficulty getting blood flow from IV catheter shows
280516 - pattern of rising problems using needle punctures. Marry and Tuniscia
280517 - deserve well done for eventually getting this done. ref SDS 0 UN6K
280518 -
280519 - [On 110607 1414 visited Charlene at VA; computer mistake
280520 - prevents following doctor's order to perform next EGD
280521 - dilation on 110729, 3 months after prior procedure,
280522 - ref SDS 81 9Q6V; Charlene scheduled next EGD dilation on
280523 - 110819 0830. ref SDS 81 N642
280524 -
280525 -
280526 -
280528 - ..
2806 -
2807 -
2808 - Background
2809 -
280901 - On 101210 EGD procedure dilated esophageal sphincter valve from 11 to
280902 - 14 mm. EGD today dilate from 14 to 17 mm. ref SDS 66 BF6L
280904 - ..
280905 - Test today was schedule in VA's letter dated 101210, received on
280906 - 101214 2330. ref SDS 68 ZG7O
280908 - ..
280909 - On 101216 1021 letter commends medical team for excellent work, and
280910 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
280912 - ..
280913 - On 110218 0730 4th EGD dilation at VA in Martinez, 110218 0730,
280914 - ref SDS 72 SR8M, and using anesthesia with Fentanyl. ref SDS 72 SR5O
280915 -
280916 -
280918 - ..
2810 -
2811 -
2812 - Progress
2813 -
281301 - Lab Blood Draw Scheduled Mid-June Prepare Meeting Primary Care July
281302 -
281303 - Follow up ref SDS 70 9P83.
281304 -
281305 - Kathy drove from Sacramento and provided transportation to VA required
281306 - to perform EGD and dilation procedure today, and with anesthesia,
281307 - planned on 110218 0730. ref SDS 72 LJ6J
281309 - ..
281310 - We stopped at Primary Care before going up to GI. Connie scheduled
281311 - blood draw on 110615 for lab to meet with Doctor Sandhu in July,
281312 - implementing the doctor's work plan on 101223 1030. ref SDS 70 9P83
281313 - Can visit VA Clinic any time for the blood draw after 110615; plan to
281314 - get the lab OA 110622, and meet with Doctor Sandhu in a week or so OA
281315 - 110706. Lab results will further support meeting with Doctor Egan the
281316 - following month in August on 110810, reported on 110420 0951.
281317 - ref SDS 76 OF8F
281319 - ..
281320 - Connie advised that the VA computer shows on 110415, Doctor Egan
281321 - ordered the lab to include a test for mercury. This implements
281322 - planning from meeting with Doctor Egan at that time on 110415 0900.
281323 - ref SDS 75 JE6O
281324 -
281325 - [On 110603 1523 scheduled meeting on 110719 0830, with
281326 - Doctor Sandhu in Primary Care at VA in Martinez; blood draw
281327 - for lab report will be performed a week or so earlier.
281328 - ref SDS 80 6I5H; supports Doctor Egan's work plan to assess
281329 - cholesterol during meeting at VA on 110807. ref SDS 75 MG3I
281330 -
281332 - ..
281333 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
281334 - GI Department VA Sacramento Medical Center Administration EGD Dilation
281335 -
281336 - Follow up ref SDS 72 K37G.
281337 -
281338 - Checked in to GI Department at 1212.
281340 - ..
281341 - Prepared patient history questionaire for the procedure.
281343 - ..
281344 - Submitted Kathy's cell phone for designated driver.
281347 -
281348 -
281349 -
2814 -
SUBJECTS
Default Null Subject Account for Blank Record
2903 -
290401 - ..
290402 - Medical Records Ordered for Case Management
290403 -
290404 - While waiting to be called for GI medical procedure, walked down the
290405 - hall to Release of Information (ROI) Department on the 2nd floor and
290406 - met with Wilma. Filled out form requesting medical chart for the work
290407 - today, and for entire period from 110220 - Apr 30. This will include
290408 - meetin with Doctor Egan in Cardiology on 110309 0900. ref SDS 73 OF8F,
290409 - and follow up meeting on 110415 0900. ref SDS 75 OF8F
290410 -
290411 - [...below need Medical Chart for measurements to assess GI
290412 - work tody. ref SDS 0 SS5R
290413 -
290414 -
2905 -
SUBJECTS
Default Null Subject Account for Blank Record
3003 -
3004 - 1311
300501 - ..
300502 - Signature Requested Blank Form on Understanding Discharge Instructions
300503 -
300504 - Marry called patient into pre-op, took vitals, and set a catheter to
300505 - inject anesthesthetic for conscious sedation, used later in the OR,
300506 - per below. ref SDS 0 SR5O
300508 - ..
300509 - Mary provided a document for signature...
300510 -
300511 - GI Discharge Instructions
300513 - ..
300514 - This document has no instructions, and no date nor time is entered.
300515 - Asked for clarification that the VA wants the patient to sign a blank
300516 - form?
300518 - ..
300519 - Marry confirmed that the GI Deparemnt wants patients to sign a blank
300520 - form before any work is performed. She said the form will be filled
300521 - out by the doctor and the nurse after the procedure, and given to the
300522 - patient in Recovery before going home, along with the patient's VA ID
300523 - card.
300525 - ..
300526 - Asked about the notation on the form that says...
300527 -
300528 - My signature indicates that I understand and have
300529 - received a copy of these instructions.
300531 - ..
300532 - Marry said obviously instructions cannot be entered until after work
300533 - is completed, and patients cannot "understand" instructions until they
300534 - are entered. VA feels getting signature on a blank form saves time,
300535 - and avoids mistakes failing to get patient's signature saying they
300536 - understand instructions. This makes case management fast and easy.
300537 - She said this is an efficiency procedure to save time.
300539 - ..
300540 - [...below after the procedure, received in Recovery
300541 - Discharge form, signed in blank form before the procedure,
300542 - filled out in Recovery, ref SDS 0 ZI87; questions pending
300543 - on measurements from examination findings, ref SDS 0 538L,
300544 - and dose for Omeprazole medicaition. ref SDS 0 6Q4H
300545 -
300546 -
3006 -
SUBJECTS
Needle Punctures Difficulty Setting IV Catheters Multiple Sticks
Needle Punctures Case Study Difficulty Setting IV Catheters Multiple
3504 -
350501 - ..
350502 - Needle Punctures Multiple Tries Setting Catheters Conscious Sedation
350503 - Pre-op Preparation Problems Getting Blood Flow for Anesthesia IV
350504 -
350505 - Marry had difficulty getting blood flow with 2 needle punctures. She
350506 - tried first on the right inner arm below the elbow, where several
350507 - veins are prominent and appear to have long straight alignement, which
350508 - facilitates setting an IV. Marry reported initial success, but then
350509 - said something like "There was a blow," to explain blood flow stopped,
350510 - causing failure of the catheter.
350512 - ..
350513 - Difficulty with needle punctures setting catheters for anesthesia and
350514 - conscious sedation has occurred previously...
350515 -
350516 - 1. In ICU prep for CABG.................... 091021 1325. ref SDS 15 737P
350517 - 2. In ICU prep for CABG.................... 091021 1508, ref SDS 15 BU5I
350518 - 3. In ICU prep for CABG.................... 091021 0716. ref SDS 15 737P
350519 - 4. In OR prep for CABG..................... 091022 0700. ref SDS 16 01F9
350520 - 5. In OR prep for CABG..................... 091022 0715. ref SDS 16 LN71
350521 - 6. In TCU "trick" use tournaquet with
350522 - hot towel solved problem................ 091101 0910. ref SDS 21 M46N
350523 - 7. In ICU prep Heller Myotomy surgery...... 091216 0600, ref SDS 31 IG4J
350524 - 8. GI clinic Martinez prep EGD - 1 try..... 100305 1000, ref SDS 42 QS91
350525 - 9. GI clinic Martinez prep EGD - 2 tries... 100827 0738, ref SDS 49 PR5P
350526 - 10. GI clinic Martinez prep EGD - 1 try..... 101210 0930, ref SDS 66 DM4G
350527 - 11. GI clinic Martinez prep EGD - 1 try..... 110218 0730, ref SDS 72 JM3G
350528 - 12. GI clinic Martinez prep EGD - 3 tries... 110429 1230, ref SDS 0 UN6K
350529 - 13. GI clinic Sacramento MD EGD - 3 tries... 141107 2000, ref SDS 86 544G
350530 - 14. GI clinic Sacramento MD EGD - 1 try..... 150421 1210, ref SDS 87 544G
350531 - 15. Radiology VAMC San Francisco set
350532 - catheter inject contrast media
350533 - for CCTA scan - 3 tries... 151019 0930, ref SDS 88 J36M
350534 - 16. GI clinic Sacramento MD EGD - 1 try..... 151204 0800, ref SDS 89 544G
350535 - 17. GI clinic Sacramento MD EGD - 1 try..... 160315 0900, ref SDS 90 544G
350536 - 18. Radiology VAMCSF....... MRI - 2 try..... 160817 0800, ref SDS 91 AN8J
350537 - 19. GI Clinic Sacramento EGD - 3 tries... 161115 0800, ref SDS 92 544G
350538 - 20. GI Clinic Sacramento EGD - 2 tries... 161206 1130, ref SDS 93 544G
350539 - 21. GI Clinic Sacramento EGD - 2 tries... 170404 0800, ref SDS 94 544G
350540 - 22. GI Clinic Sacramento EGD - 2 tries... 170516 0800, ref SDS 95 544G
350541 - 23. GI Clinic Sacramento EGD - 2 tries... 171031 0800, ref SDS 96 544G
350542 - 24. GI Clinic Sacramento EGD - 2 tries... 171128 0800, ref SDS 97 544G
350543 - 25. GI Clinic Sacramento EGD - 2 tries... 180417 0800, ref SDS 98 544G
350544 - 26. GI Clinic Sacramento EGD - 2 tries... 180814 0800, ref SDS 99 JA4N
350545 - 27. GI Clinic Sacramento EGD - 3 tries... 181002 0800, ref SDS A0 HU6L
350546 - 28. GI Clinic Sacramento EGD - 2 tries... 190215 0800, ref SDS A1 JA4N
350547 - 29. GI Clinic Sacramento EGD - 2 tries... 190521 0930, ref SDS A2 JA4N
350548 - 30. GI Clinic Sacramento EGD - 2 tries... 200529 0930, ref SDS A3 JA4N
350550 - ..
350551 - Today, on removing the failed catheter, the puncture wound began
350552 - bleeding, and required a special bandage. Marry noted anomoly of
350553 - blood failing through the catheter needle, but flowing freely from the
350554 - needle puncture. Marry tried a second time to inject a catheter on
350555 - top of the right hand. This also failed. Marry left the room to get
350556 - help.
350558 - ..
350559 - [On 110520 1537 medical chart Nurse Pre-proc Check List for
350560 - EGD dilation on 110429, reports no difficulties setting IV
350561 - for sedation, nor that this required 3 tries in both arms.
350562 - ref SDS 78 GV6O
350564 - ..
350565 - There was discussion today about hiking 8 miles this morning, and
350566 - having very minimal water intake, i.e., a few sips from a fountain at
350567 - Lafayette Reservoir about 1000. Marry noted that heavy exercise and
350568 - minimal water intake causes dehydration, which impedes blood flow.
350569 - She also commented on the arm being well muscled as contributing to
350570 - difficulty setting IVs.
350571 -
350572 - [On 110506 2017 Kathy reports problems setting IVs in her
350573 - work. ref SDS 77 KP7X
350575 - ..
350576 - [On 110506 2017 Kathy advises that IV problems are the
350577 - biggest complaint in patient quality care surveys.
350578 - ref SDS 77 7G8N
350580 - ..
350581 - [On 110506 2017 Kathy explains that muscle creates natural
350582 - breaks in veins that complicate setting IVs. ref SDS 77
350583 - 6B8J
350585 - ..
350586 - [On 110601 0652 Kathy reported another difficult IV
350587 - situation. ref SDS 79 MK6I
350589 - ..
350590 - [On 141107 0800 Gale set IV catheter for sedation to
350591 - perform EGD dilation procedure at VA Medical Center in
350592 - Sacramento - took 3 tries. ref SDS 85 544G
350594 - ..
350595 - The next day, noticed these locations are black and blue, indicating
350596 - trauma. This has not previosly occurred getting IV needle punctures
350597 - for medical care the past 50 years. Millie began suffering severe
350598 - trauma from needle punctures, which led to surgery implanting a port
350599 - catheter, reported on 040318 1615. ref SDS 2 CO3G
350601 - ..
350602 - Analysis at the VA today, aligns with experience at Kaiser in Millie's
350603 - patient history, showing the "trick" to successfully setting an IV
350604 - catheter with needle puncture is drinking water prior to arriving at
350605 - the hospital for care, reported at Kaiser on 031205 1645. ref SDS 1
350606 - CF3F Eventually, in Millie's case, all the "tricks" failed due to
350607 - continuing success treating cancer. She lived long enough for scar
350608 - tissue to increase in all locations medically appropriate to her
350609 - patient profile for needle penetrations, causing overwhelming pain for
350610 - the patient, and deep emotional distress for providers, reported on
350611 - 080425. 080425 1509, ref SDS 10 FP6F
350612 -
350613 - [...below Discharge document notifies patient to request
350614 - care for severe inflammation from needle punctures; the
350615 - record shows the next day, mild inflammation at 2 failed
350616 - needle puncture sites does not require care, but presents a
350617 - "canary in the mine" for future concern. ref SDS 0 173F
350619 - ..
350620 - [On 110506 2017 Kathy reminds that drinking a lot of water
350621 - in order make setting an IV easier for anesthesia conflicts
350622 - with NPO protocol required to avoid complications and death
350623 - from anesthesia. ref SDS 77 6B8J
350625 - ..
350626 - Tunisia arrived about 20 minutes later. She was successful setting an
350627 - IV on the 3rd try. The first two needle punctures were noticably
350628 - painful. Did not feel at all needle penetration setting the catheter
350629 - on the top of the left hand. Thanked Tunsia for outstanding work.
350631 - ..
350632 - Tuniscia advised that after patients have numerous IV needle
350633 - punctures, getting sufficient blood flow for procedures becomes
350634 - difficult, and so a matter of luck. Thanked her again for being
350635 - "lucky" today.
350636 -
350637 - [On 110506 2017 Kathy reports problems setting IVs in her
350638 - work. ref SDS 77 KP7X
350640 - ..
350641 - [On 110506 2017 Kathy advises that IV problems are the
350642 - biggest complaint in patient quality care surveys.
350643 - ref SDS 77 7G8N
350645 - ..
350646 - [On 110601 0652 Kathy reported another difficult IV
350647 - situation. ref SDS 79 MK6I
350649 - ..
350650 - [On 141107 0800 Gale set IV catheter for sedation to
350651 - perform EGD dilation procedure at VA Medical Center in
350652 - Sacramento - took 3 tries. ref SDS 85 544G
350654 - ..
350655 - The doctor setting the next procedure 3 months out, per below,
350656 - ref SDS 0 LJ6J, gives scarring from needle penetrations more time to
350657 - heal. Need to remember to drink a lot of water next time.
350658 -
350659 - [...below Discharge document notifies patient to request
350660 - care for severe inflammation from needle punctures; the
350661 - record shows the next day, mild inflammation at 2 failed
350662 - needle puncture sites does not require care, but presents a
350663 - "canary in the mine" for future concern. ref SDS 0 173F
350665 - ..
350666 - A third (male) nurse entered patient history into the computer for the
350667 - record on work today.
350668 -
350669 -
350670 -
3507 -
SUBJECTS
Default Null Subject Account for Blank Record
3603 -
3604 - 1409
360501 - ..
360502 - Consent Signed Continue Dilation Improve Swallowing
360503 -
360504 - Doctor Lee arrives. Shook hands. Signed consent for the procedure.
360506 - ..
360507 - Explained continued reduced side effects from high dose Omeprazole
360508 - ordered on 101210 0930. ref SDS 66 ZN4M Advised that severe skin
360509 - dryness of face and feet, including bleeding feet has declined. Still
360510 - seem very tired taking 80 mg Omeprazole per day, reported previously
360511 - during meeting at the VA on on 110218 0730. ref SDS 72 SR5N
360513 - ..
360514 - The doctor left to continue work with other patients.
360515 -
360516 -
360518 - ..
3606 -
3607 -
3608 - 1432
3609 -
360901 - Kendall walked patient into OR.
360902 -
360903 - In the OR, Kendall was assisted by Tunisia, who had done an excellent
360904 - job setting up the IV, per above. ref SDS 0 SR8M Tom also assisted,
360905 - and remembered me from prior work on 101210 0930. ref SDS 66 IR4J
360907 - ..
360908 - Tuniscia applied Lidocaine to numb the throat. She used a new
360909 - procedure. Rather than the patient swallow from a cup and gargele a
360910 - thick viscous substance, as was done for prior EGD, reported recently
360911 - on 110218 0730. ref SDS 72 PQWY, and citing work on 101210 0930,
360912 - ref SDS 66 PL5O, today, Tuniscia used an instrument to squirt with a
360913 - long tube instrument the back of the throat, and then swallow the
360914 - Lidocaine. This is done twice, once on each side of the throat.
360915 -
360916 -
3610 -
SUBJECTS
Default Null Subject Account for Blank Record
3703 -
370401 - ..
370402 - Chronic Swallowing Requires Dilation Conflicts Objectives Surgery
370403 - Quality Care Review Heller Myotomy Surgery Align Results with Objectives
370404 -
370405 - When Doctor Lee entered the OR, we discussed Doctor Egan's work plan
370406 - to add aspirin to the list of medications, and for the purpose of
370407 - preventing blood clots (thrombus, emoblism) that cause complications
370408 - for CAD, including death, reported on 110415 0900. ref SDS 75 UR7L VA
370409 - medical chart for work in Primary Care says in part that aspirin
370410 - presents risks of gastric ulcers and bleeding, reported on 101223
370411 - 1030. ref SDS 70 454F
370413 - ..
370414 - Doctgor Lee asked about results from prior dilation on 110218 0730?
370415 - ref SDS 72 EU9G Kendall asked if there is a feeling of food stuck in
370416 - the esophagus at the moment?
370418 - ..
370419 - Reported immediate feeling of minor congestion in the throat from
370420 - eating dinner yesterday on Thursday evening 110428 about 1700,
370421 - reported in case study on 101010 0744. ref SDS 52 O48F Asked the team
370422 - to write in the medical chart actual findings today, when the doctor
370423 - accesses the throat using a camera to make direct examination of
370424 - current conditions for EGD.
370426 - ..
370427 - Asked about occassional horseness talking in meetings and calls. For
370428 - example today in the OR laying on the table and talking to the team
370429 - the voice seems somewhat raspy.
370431 - ..
370432 - Doctor Lee advised that raspy voice is associated with chronic throat
370433 - congestion from incomplete swallowing.
370435 - ..
370436 - The doctor explained swallowing problems originally diagnosed as
370437 - achalasia, reported on 051202 1430. ref SDS 3 5B5K, now occur from
370438 - acid burn causing a "stricture" at the same location on the lower
370439 - esophageal sphincter valve, which reduces the size of the valve for
370440 - passing food into the stomach. The symptom is identical though
370441 - reduced in degree from achalasia treated beginning on 051202 1430.
370442 - ref SDS 3 5B5K
370443 -
370444 - [...below on 110429 1230 after EGD dilation procedure,
370445 - discharge documentation shows doctor's handwritten diagram
370446 - of LESV, with notation of "narrow area," aligns with
370447 - explanation during meeting that "stricture" in the medical
370448 - chart refers to LESV. ref SDS 0 949J
370450 - ..
370451 - Reported continued significantly improved swallowing after EGD
370452 - dilation from 11 to 14 mm on 101210, of lower esophageal sphincter
370453 - valve (LESV), and at that time adding triamcinolone steriod
370454 - injection, beginning on 101211, and from prior follow up EGD and
370455 - dilation from 11 to 14 mm, reported on 110218 0730. ref SDS 72 SS5R
370456 - Continued improved swallowing from 110219, is shown in case study on
370457 - 101010 0744. ref SDS 52 IN7K
370459 - ..
370460 - Doctor Lee was pleased that adding tramcinolone steriod injection to
370461 - LESV has been effective resisting contraction of LESV since prior
370462 - dilation the same day on 110218. He feels this validates the work
370463 - plan at that time showing the steriod is effective. ref SDS 72 SR4G
370464 -
370465 - [...below on 110429 1230 after EGD dilation procedure the
370466 - doctor advised that he added triamcinolone injection again
370467 - today in order to restrict contraction of LESV, and in
370468 - order to aid swallowing and reduce vomitting. ref SDS 0
370469 - SS5N
370471 - ..
370472 - Doctor Lee asked if there have been any vomitting episodes since
370473 - treatment on 110218, when the lower esophageal sphincter valve, also
370474 - called a "stricture," in the medical chart, was dilated to 14 mm.
370476 - ..
370477 - On the OR table recalled 2 events.
370479 - ..
370480 - On 110330, vomitted nearly all of a patty melt (hamburger) sandwich,
370481 - reported in case study on 101010 0744. ref SDS 52 7Q8I A few weeks
370482 - later on 110417, same occurred after eating a corned beef (Reuben)
370483 - sandwich. ref SDS 52 QZ5K
370485 - ..
370486 - We reviewed the record meeting with Doctor Stewart at the VA Medical
370487 - Center in San Francisco. On 091030, The doctor presented a work plan
370488 - to perform Heller Myotomy surgery for comprehensive recovery from
370489 - achalasia, which was intended to replace treatment with pneumatic
370490 - dilation. ref SDS 19 P69G The VA's work plan was approved, and work
370491 - was performed on 091216 0600. ref SDS 31 KE9U Subsequently, beginning
370492 - on 100305, VA has performed 5 pneumatic dilations required to restore
370493 - swallowing. This record indicates care for a chronic condition,
370494 - planned to be obviated by approving surgery at the Medical Center.
370495 -
370496 -
370498 - ..
370499 - Medical Records Access Problematic for Timely Health Care Decisions
370500 -
370501 - Kendhal used a computer in the OR at the VA Clinic in Martinez, to
370502 - find the record of Heller Myotomy surgery at the Medical Center in San
370503 - Francisco. He reported finding no record of Doctor Stewart's surgery,
370504 - and asked for the date of the work?
370506 - ..
370507 - Difficulty finding medical records was previously reported by Doctor
370508 - Brzezinski in the OR, and while preparing the work plan for anesthesia
370509 - to support heart surgery at the VA Medical Center in San Francisco on
370510 - 091022 0700. ref SDS 16 JF9K Last year the VA was cited for
370511 - increasing access to medical records on the computer, reported on
370512 - 100911 0800, ref SDS 50 OL50; challenges remain at the VA as
370513 - everywhere to find critical details in time to save lives, time and
370514 - money. ref SDS 50 3G5J
370515 -
370516 - [On 110727 1238 Melissa had difficulty using the VA
370517 - computer in the Martinez Primary Care Department to find
370518 - Doctor Egan's work plan in the Cardiology Department on
370519 - adding mercury to the lab. ref SDS 82 A25H
370521 - ..
370522 - Advised that Doctor Stewart and her team did the work on 091216.
370523 - 091216 0600, ref SDS 31 KE9U
370525 - ..
370526 - Kendall said the medical chart for 091216, is not showing up today on
370527 - the computer in the OR at the VA Clinic in Martinez.
370529 - ..
370530 - Though Kendall could not display the record of surgery to recover from
370531 - Achalasia on 091216, on the computer in the OR, Doctor Lee seemed to
370532 - recall seeing the record sometime earlier. He feels his examinations
370533 - beginning on 100305, show that surgery on 091216, accomplished VA
370534 - objectives in the medical chart for work on 091216.
370535 -
370536 -
370538 - ..
370539 - Surgery Correlate Results with Objectives Improve Patient Care
370540 -
370541 - The "Operation Report" in the medical chart for work on Achalasia and
370542 - performed at the VA Medical Center in San Francisco on 091216, was
370543 - received from the VA on 100928. ref SDS 51 SO4N
370545 - ..
370546 - The section on Clinical Indications says in part...
370547 -
370548 - Risks, benefits, and alternatives were discussed with the
370549 - patient regarding laparoscopic Heller myotomy and Dor
370550 - fundoplication and after all questions were answered, informed
370551 - consent was obtained. ref DRP 1 SO5F
370553 - ..
370554 - Merely saying "benefits and alternatives were discussed," begs the
370555 - question of what benefits and what alternatives were presented that
370556 - justified approval for surgery.
370558 - ..
370559 - This might be a good time for quality care review of results in
370560 - relation to benefits and alternatives, per above. ref SDS 0 DD4N
370561 - Asked Doctor Lee to adivse procedure for scheduling a meeting with
370562 - Doctor Stewart for follow up. If the scope of surgery on 091216, was
370563 - reduced was reduced from planning on 091030, leading to continuing
370564 - remedial work with pneumatic dilation, might there be additional
370565 - surgery that can provide a comprehensive solution planned in the
370566 - meeting on 091030 0810? ref SDS 19 P69G
370568 - ..
370569 - Doctor Stewart planned to prevent scarring the esophagus by surgically
370570 - constructing a "flap" to prevent backflow from the stomach.
370571 - ref SDS 19 OY64 Since Doctor Lee's work shows acid burn on LESV has
370572 - caused restricted swallowing intended to be solved with Heller Myotomy
370573 - surgery, Doctor Stewart can investigate the flap for alignment with
370574 - planning, and whether additional work can eliminate current problems
370575 - in this case, and/or for other patients.
370577 - ..
370578 - Objectives today are to find elevated treatment wtih Omeprazole has
370579 - been effective reducing acid burn scarring on LESV, which will be
370580 - established by examination finding LESV did not contract again, but
370581 - remains at 14 mm dilated during prior work on 110218 0730. At that
370582 - time, previous dilation on 101210, to 14 mm was found to have
370583 - contracted back to 11 mm on 110218. ref SDS 72 SS5R
370584 -
370585 - [...below Discharge document shows handwriting saying LESV
370586 - dilated to size of "ring finger." ref SDS 0 9498
370587 -
370588 -
370589 -
3706 -
SUBJECTS
Default Null Subject Account for Blank Record
3803 -
380401 - ..
380402 - EGD Dilation Procedure with Anesthesia
380403 -
380404 - After discussing case management, Kendall gave Fentanyl, and then
380405 - other drugs for conscious sedation, used for anesthetic, reported in
380406 - medical chart for procedure on 100827 0738. ref SDS 49 JE9V
380407 -
380408 -
380410 - ..
3805 -
3806 -
3807 - 1613
3808 -
380801 - Awake in recovery.
380802 -
380803 - Nurse removed IV catheter. The nurse called Kathy on the cell phone
380804 - advising patient can go home.
380806 - ..
380807 - Dressed and met with Doctor Lee.
380809 - ..
380810 - Doctor Lee advised that...
380811 -
380812 - 1. Esophagitis scar formation - Doctor Lee advised that he
380813 - found improvement. There is less infection and acid burn
380814 - since prior examination on 110218. ref SDS 72 EU9G
380815 -
380816 - The doctor presented photographs taken during the procedure
380817 - today and showing esophageal tissue is uniform in natural
380818 - color and texture, indicating reduced disease. The 4
380819 - pictures observed during the meeting seem devoid of any
380820 - medical problems. Pathology report on biopsies taken today
380821 - will further assess esophagitis.
380822 -
380823 - [...below, Discharge documentation shows handwritten
380824 - report saying "Esophagus looked better." ref SDS 0 GP5L
380826 - ..
380827 - [On 110520 1537 photographs missing from medical chart
380828 - received from VA, ref SDS 78 548L, for procedure today
380829 - on 110429. ref SDS 0 MM43
380831 - ..
380832 - [On 110520 1537 medical chart received for work today
380833 - shows no record of biopsies to assess esophagitis
380834 - requirements for elevated dose Omeprazole 80 mg per day.
380835 - ref SDS 78 3V5K
380837 - ..
380838 - Dilate LESV 16 MM Size Ring Finger
380839 -
380840 - 2. Lower esophageal sphinchter valve (LESV) - the doctor
380841 - seemed to say that examination today found less contraction
380842 - than occurred for prior EDG and dilation on 110218 0730.
380843 - ref SDS 72 SS5R He was able to dilate the stricture
380844 - (stenosis) to about the size of the "ring finger." The
380845 - doctor did not say that objective was met to dilate the
380846 - stricture to 17 mm, discussed prior to the procedure, per
380847 - above. ref SDS 0 OW5N
380848 -
380849 - [...below, Discharge documentation shows the doctor
380850 - wrote by hand that stricture was dilated to the size of
380851 - "ring finger." ref SDS 0 9498
380853 - ..
380854 - [On 101010 0744 case study for 110504, vomitting 90%
380855 - likely due to eating too fast, with big bites - big
380856 - mistake, despite report that esophageal stricture was
380857 - dilated on 110429, larger than expected. ref SDS 52 SY8F
380859 - ..
380860 - [On 101010 0744 0% vomitting eating hamburger and fries
380861 - reflects eating slowly and drinking liquid with meal,
380862 - ref SDS 52 Z36H, and notice tody of success dilating
380863 - stricture at LESV to wider diameter, per above.
380864 - ref SDS 0 SS5R
380866 - ..
380867 - [On 110819 EGD dilation follow up. ref SDS 83 SR8M
380869 - ..
380870 - Whose ring finger?
380872 - ..
380873 - Patient's ring finger measures about .8 inches above the
380874 - knuckle, where rings are typically worn. This converts to
380875 - 20 mm, significantly exceeding objectives for dilating LESV
380876 - to 17 mm.
380878 - ..
380879 - Need Medical Chart for actual measurements on degree of
380880 - contraction found by examination, and amount dilated. The
380881 - Medical Chart for this work was ordered from Wilma in
380882 - Release of Information Department, prior to starting work
380883 - in GI Department, reported above. ref SDS 0 4U55
380885 - ..
380886 - Addendum to one of many documents filed by VA for work today
380887 - states...
380889 - ..
380890 - 04/29/2011 ADDENDUM STATUS: COMPLETED
380891 - egd & tts dilation 152026 dictated: dilated to 16.5mm,
380892 - ref DRP 2 PSRX,
380894 - ..
380895 - [On 110520 1130 received medical chart shows conflicting
380896 - results for dilation, Proc report item #6 seems to say
380897 - dilation was done in 2 stages; first stage from 12 - 15,
380898 - and 2nd stage from 15 - 18, ref SDS 78 QO4I; however, an
380899 - addendum to pre-proc exam item #4 says only 16.5 mm.
380900 - ref SDS 78 LX5I
380902 - ..
380903 - Kenalog 40 mg/1 ml was injected within the stricture
380904 - with 3.5 ml using a BSC sclerotherapy needle. ref DRP 2 QXXR
380906 - ..
380907 - [On 110520 1130 received medical chart showing 3.5mL
380908 - Triamcinolone injected into LESV. ref SDS 78 426H
380910 - ..
380911 - LESV Dilated
380912 - Date from to
380913 - 110429 13 16.5 triamcinolone...3.5mL.. ref SDS 0 U23I
380914 - 110218 11 14 w triamcinolone...2.0mL.. ref SDS 72 AA5O
380915 - 101210 11 14.......................... ref SDS 66 H347
380916 - 100827 11 15.......................... ref SDS 49 JE6X
380917 - 100305 11 15.......................... ref SDS 42 WR6L
380919 - ..
380920 - 3. Steriod injected into the stricture (which is LESV, per
380921 - doctor's diagram in Discharge document shown below,
380922 - ref SDS 0 DU6J) and described as Kenalog 40 mg/ml
380923 - injections in Progress Notes. ref DRP 2 QXUT Doctor Lee
380924 - explained Kenalog is a trade name for triamcinolone
380925 - injections that help prevent contraction again from size of
380926 - "ring finger" dilated today, also, shown in Doctor's
380927 - handwritten notes, below, ref SDS 0 9498, and continuing
380928 - procedure injecting triamcinolone steriod started by the
380929 - doctor during EGD Dilation and reported in Progress Notes
380930 - on 110218 0730, ref SDS 72 SS5N, following report of severe
380931 - swallowing problems after prior EGD dilation. ref SDS 72
380932 - SR4G
380933 -
380934 - LESV Dilated
380935 - Date from to
380936 - 110429 13 16.5 triamcinolone.... ref SDS 0 TQ3I
380937 - 110218 11 14 w triamcinolone.... ref SDS 72 AA5O
380938 - 101210 11 14.................... ref SDS 66 H347
380939 - 100827 11 15.................... ref SDS 49 JE6X
380940 - 100305 11 15.................... ref SDS 42 WR6L
380942 - ..
380943 - [On 111115 1300 doctor Impressions in Progress Notes for
380944 - next procedure report that adding triamcinolone steriod
380945 - injection to resist contraction of LESV was effective to
380946 - avoid severe swallowing and vomitting problems,
380947 - ref SDS 84 AW6J; yet, for some reason not presented in
380948 - the record triamcinolone injection was not performed on
380949 - 111115. ref SDS 84 IR57
380951 - ..
380952 - 4. Omeprazole dose held at 80 mg per day despite finding
380953 - esophagus looks better, per finding #1 above. ref SDS 0
380954 - MM43
380956 - ..
380957 - Doctor Lee reported having read Doctor Egan's work plan for
380958 - adding aspirin to current regimen of daily medications,
380959 - discussed recently on 110415 0900. ref SDS 75 UR7L
380961 - ..
380962 - The doctor seemed to indicate that Omeprazole even in high
380963 - dose reduces side effects of aspirin. He therefore feels
380964 - there is no conflict taking aspirin with current
380965 - prescription for Omperazole. The doctor did not discuss
380966 - published studies noted by Doctor Egan in the meeting on
380967 - 110415, that indicate conflict between aspirin and low dose
380968 - Ompeprazole 20 mg. ref SDS 75 UR7L
380969 -
380970 - [...below, Discharge documentation shows handwritten
380971 - guidance that seems to say do not change Omeprazole 40
380972 - mg per day, ref SDS 0 6Q4H, and Doctor Lee believes high
380973 - dose Omeprazole 80 mg per day, does not conflict with
380974 - taking low dose aspirin recommended by Doctor Egan for
380975 - cardiology risk management. ref SDS 0 6Q5K
380977 - ..
380978 - 5. EGD procedure scheduled in 3 months during July.
380979 -
380980 - Doctor Lee said that if the VA computer schedules the next
380981 - meeting again in the afternoon, like today, call the VA and
380982 - he will arrange for meeting at 0730, that worked well for
380983 - the prior procedure on 110218 0730. ref SDS 72 K37G
380984 -
380985 - [...above, scheduling next procedure in 3 months, gives
380986 - scarring more time heal so that setting IV catheters is
380987 - easier for the team. ref SDS 0 D95L
380989 - ..
380990 - [...below, Discharge documentation shows doctor's 9th
380991 - handwritten note planning next meeting in 3 months.
380992 - ref SDS 0 GP9I
380994 - ..
380995 - [On 110520 1537 received medical chart for 110429
380996 - showing Post Proc nurses notes that schedule next EGD
380997 - and Dilation procedure in 3 months. ref SDS 78 ZM6N
380999 - ..
381000 - [On 110607 1414 visited Charlene at VA; computer mistake
381001 - prevents following doctor's order to perform next EGD
381002 - dilation on 110729, 3 months after prior procedure,
381003 - ref SDS 81 9Q6V; Charlene scheduled next EGD dilation on
381004 - 110819 0830. ref SDS 81 N642
381005 -
381006 -
381007 -
381008 -
3811 -
SUBJECTS
Default Null Subject Account for Blank Record
3903 -
3904 - 1643
390501 - ..
390502 - GI Discharge Instructions Comprehensive Handwriting Problematic
390503 -
390504 - Follow up ref SDS 72 PR4S.
390505 -
390506 - Received EGD documentation...
390507 -
390508 - Department Veterans Administration
390509 - VA Northern California Health Care System
390510 - Gastroenterology Department
390512 - ..
390513 - GI Discharge Instructions
390514 -
390515 - 1. Do not drive a motor vehicle, operate machinery or make
390516 - important decisions for at least 24 hours after the procedure.
390517 - The medictions given during the procedure may effect how you
390518 - act and think.
390520 - ..
390521 - 2. You may resume your usual diet after the procedure unless
390522 - instructed otherwise.
390524 - ..
390525 - 3. You may experience some abdominal bloating, cramping or gas.
390526 - Walking around the house or drinking warm weak tea or black
390527 - coffee may help.
390529 - ..
390530 - 4. You might have a mild sore throat following an EGD which can be
390531 - relieved by gargling with warm salt water.
390533 - ..
390534 - Nurse circled #4 with blue ink. Did not notice soreness in the
390535 - throat.
390537 - ..
390538 - Discharge instructions continue...
390539 -
390540 - 5. Continue all medications as directed and begin new medications
390541 - as prescribed.
390542 -
390543 - 6. Do not take aspirin, products containing aspirin, or
390544 - anti-inflammatory agents (i.e., Motrin, Advil, etc) for the
390545 - next *** OK today *** days.
390547 - ..
390548 - Nurse wrote with red ink "OK today" in the blank.
390550 - ..
390551 - Discharge instructions continue...
390552 -
390553 - 7. Warfarin Coumadin Patients
390555 - ..
390556 - Nurse circled #7 and drew a line with blue ink pen through it,
390557 - reflecting patient is not taking these medications.
390559 - ..
390560 - Discharge instructions continue...
390561 -
390562 - 8. If you have any of the following symptoms, please call the
390563 - clinic checked below for advice....
390564 -
390565 - Mon - Fri......................... 925 372 2000 ext 5168
390566 - Weekends Holidays................. 800 382 8387
390567 -
390568 - A. Passing or vomitting a large amount of blood.
390569 - B. Passing black or tarry stools.
390570 - C. Fever over 100 degrees with or without chills.
390572 - ..
390573 - D. Severe inflammation at the needle puncture site.
390575 - ..
390576 - Next day mild inflammation occurred at the two failed IV catheter
390577 - sites, explained above, ref SDS 0 124H, so not severe enough to
390578 - require care. May be "canary in the mine" portending future concern.
390580 - ..
390581 - Discharge instructions continue...
390582 -
390583 - E. Severe abdominal or chest pain.
390584 - F. Shortness of breath or tightness in your chest.
390585 - G. Loss of consciousness or frequent dizziness.
390586 - H. Emergency go to nearest hospital or dial 911.
390588 - ..
390589 - 9. Additional instructions (i.e., Sitz Bath, Medications, etc)
390591 - ..
390592 - There is handwriting with black ink differentiated from blue ink,
390593 - evidently used by the nurse, and presumably entered by the doctor
390594 - showing a medical diagram with handwrtten comments...
390595 -
390596 - | |
390597 - | | Throat
390598 - | |
390599 - | | Lower esophageal sphincter (LES) valve
390600 - ||||||||
390601 - |||||||| <------- narrow area
390602 - / \
390603 - / -----\
390604 - | -\
390605 - | - Stomache
390606 - | |
390607 - / /
390608 - / --------- /
390609 - | /
390610 - \ \
390612 - ..
390613 - The doctor's diagram today, looks similar to the drawing received from
390614 - Doctor Stewart during a meeting at the VA Medical Center in San
390615 - Francisco, and for the purpose of planning Heller Myotomy surgery to
390616 - replace pneumatic dialtion for solving achalasia, reported on 091030
390617 - 0810. ref SDS 19 GM5I
390619 - ..
390620 - The doctor's handwritting in black ink says "narrow area" next to the
390621 - diagram that seems to depict LESV, and so indicates that "stricture"
390622 - entered in the medical chart references LESV is the "narrow area" that
390623 - restricts swallowing, and which was intended to be resolved with
390624 - Heller Myotomy surgery on 091216, Discussion prior to starting EGD
390625 - and dilation procedure, the doctor indicated that surgery solved
390626 - achalasia, but subsequent acid burn caused LESV to swell, thereby
390627 - continuing swallowing problem, per above. ref SDS 0 DD3I
390629 - ..
390630 - Doctor further writes...
390631 -
390632 - 1. Narrow area dilated.
390633 - 2. Opening now the size of ring finger.
390635 - ..
390636 - This seems to relate progress dilating LESV from 14 to 17 mm, assuming
390637 - LESV did not contract back to 11 mm as occurred previously, discussed
390638 - with the doctor prior to starting work, shown above. ref SDS 0 OW5N
390639 -
390640 - [On 101010 0744 case study for 110504, vomitting 90% likely
390641 - due to eating too fast, with big bites - big mistake,
390642 - despite report that esophageal stricture was dilated on
390643 - 110429, larger than expected. ref SDS 52 SY8F
390645 - ..
390646 - [On 101010 0744 0% vomitting eating hamburger and fries
390647 - reflects eating slowly and drinking liquid with meal,
390648 - ref SDS 52 Z36H, and notice tody of success dilating
390649 - stricture at LESV to wider diameter, per above. ref SDS 0
390650 - SS5R
390652 - ..
390653 - Analysis of doctor patient discussion in Recovery post procedure
390654 - indicates patient "ring finger" measures about 20 mm, which exceeds
390655 - objectives for expanding stricture, and notes actual measurements are
390656 - needed in Medical Chart to assess work today. ref SDS 0 SS5R
390658 - ..
390659 - Doctor's handwriting continues...
390660 -
390661 - 3. Small bites will always apply.
390663 - ..
390664 - The doctor's recommendations align with notice in the letter to the
390665 - medical team reporting that swallowing improved with "soft food" and
390666 - eating slowly with plenty of liquid during meals, reported on 110329
390667 - 2213. ref SDS 74 0E3T
390668 -
390669 - [On 101010 0744 case study for 110504, vomitting 90% likely
390670 - due to eating too fast, with big bites - big mistake,
390671 - despite report that esophageal stricture was dilated on
390672 - 110429, larger than expected. ref SDS 52 SY8F
390674 - ..
390675 - Doctor's handwriting continues...
390676 -
390677 - 4. Esophagus looked better.
390679 - ..
390680 - Doctor Lee's comment aligns with doctor/patient post-procedure
390681 - discussion in Recovery, and with photographs that seem to show the
390682 - esophagus has no indications of disease. ref SDS 0 MM43
390684 - ..
390685 - Doctor's handwriting continues...
390686 -
390687 - 5. Swallowing will remain the same (as now).
390689 - ..
390690 - 6. Do not change Omeprazole dose now 40 mg daily.
390692 - ..
390693 - Need clarification on dose for Omeprazole??
390695 - ..
390696 - If the doctor feels Omeprazole 40 mg should be taken daily, this
390697 - changes the prescription for 80 mg daily on 101210 0930. ref SDS 66
390698 - HW8H Medical chart Recommendations entered in section 12 on 101210,
390699 - appear to confirm prescription for taking 80 mg/day. ref SDS 66 5I5H
390701 - ..
390702 - Discharge instructions continue...
390703 -
390704 - 7. Doctor Lee does not see any contradiction to 8/mg
390706 - ..
390707 - 8. Aspirin use = Omeprazole to protect from bleeding side
390708 - effects
390710 - ..
390711 - This seems to align with doctor/patient post-procedure discussion in
390712 - the Recovery room, per above, ref SDS 0 SS8I, and addresses in part
390713 - recent discussion with Doctor Egan on taking aspirn with Omeprazole,
390714 - reported on 110415 0900. ref SDS 75 UR7L
390716 - ..
390717 - Discharge instructions continue...
390718 -
390719 - 9. Next dilation in 3 months.
390721 - ..
390722 - Aligns with doctor/patient post-procedure discussion in recovery room,
390723 - per above. ref SDS 0 LJ6J
390724 -
390725 -
390726 - [On 110607 1414 visited Charlene at VA; computer mistake
390727 - prevents following doctor's order to perform next EGD
390728 - dilation on 110729, 3 months after prior procedure,
390729 - ref SDS 81 9Q6V; Charlene scheduled next EGD dilation on
390730 - 110819 0830. ref SDS 81 N642
390732 - ..
390733 - Discharge instructions continue...
390734 -
390735 - 10. Follow up with [ ] Primary Care Provider [ ] GI clinic
390736 -
390737 - Nothing is checked in this section, but no follow up required.
390738 -
390739 - Date/Time.....................
390741 - ..
390742 - Discharge document is not dated.
390744 - ..
390745 - Discharge instructions continue...
390746 -
390747 - 11. Nurse Signature
390749 - ..
390750 - This section is illegible.
390752 - ..
390753 - Discharge instructions continue...
390754 -
390755 - 12. Patient's Signature Date/Time
390756 -
390757 - 13. My signature indicates that I understand and have received a
390758 - copy of these instructions.
390760 - ..
390761 - This form was signed before instructions were entered in handwriting,
390762 - set out above, ref SDS 0 DU6J, and noted above reporting VA asked for
390763 - signature on blank form prior to starting work. ref SDS 0 SR8M
390765 - ..
390766 - Discharge instructions continue...
390767 -
390768 - 14. Imprint Patient Data Card (name address social security
390775 - ..
390776 - 15. Medical Record Nursing Documentation
390778 - ..
390779 - 16. VA Form 10-9096
390780 -
390781 -
390782 -
390783 -
391132 - ..
391133 - Posted expense ledger up to date...
391136 -
391137 -
391138 -
391139 -
3912 -
SUBJECTS
Default Null Subject Account for Blank Record
4003 -
400401 - ..
400402 - Medical Records Nursing Note Meeting 110429
400403 - Nursing Note Meeting 110429 Medical Records
400404 - 110429 Nursing Note Meeting Medical Records
400405 -
400406 -
400407 - 1. LOCAL TITLE: Nursing Note 60251
400408 - STANDARD TITLE: NURSING NOTE
400409 - DATE OF NOTE: APR 29, 2011@16:52 ENTRY DATE: APR 29, 2011@16:53:24
400410 - AUTHOR: BAKERJIAN,MARCIA A EXP COSIGNER:
400411 - URGENCY: STATUS: COMPLETED
400413 - ..
400414 - 2. PLAN OF CARE -Post- Procedure SEDATION
400415 -
400416 - 1. Potential for altered level of consciousness or sensory
400417 - motor deficit at discharge
400419 - ..
400420 - 2. Outcome: Patient will remain free of injury and will be
400421 - oriented x 3 prior to discharge.
400423 - ..
400424 - 3. Patient will be fully awake and oriented, exhibit the
400425 - ability to cough and deep breath prior to discharge,
400426 - ambulate with steady gain as appropriate per pre-procedure,
400427 - with minimal pain, and minimal nausea.
400429 - ..
400430 - 4. Above actions completed
400432 - ..
400433 - 3. Potential knowledge deficit for self care
400435 - ..
400436 - 4. Outcome: Patient and/or caregiver will verbalize an
400437 - understanding of discharge instructions
400439 - ..
400440 - Discharge instructions will be provided to patient. Nurse will
400441 - assure all questions are answered, and have patient repeat
400442 - instructions as they understood them. Nurse will individualize
400443 - teaching based on patients' ability to understand.
400445 - ..
400446 - 5. Specialized instructions:
400447 -
400448 - SEE POST GI INSTRUCTIONS NOTES
400450 - ..
400451 - 6. Above actions completed
400452 -
400454 - ..
400455 - Discharge Instructions Procedure 110429
400456 - 110429 Discharge Instructions Procedure
400457 -
400458 -
400459 - 1. Discharge Instructions - Upper Endoscopy
400460 - GI Discharge Instructions
400462 - ..
400463 - Upper Endoscopy
400464 -
400465 - 1. Do not drive a motor vehicle, operate machinery or make
400466 - important decisions for at least 24 hours effect how you
400467 - act and think.
400469 - ..
400470 - 2. You may resume your usual diet after the procedure unless
400471 - instructed otherwise. SMALL BITES AND CHEWED THOROUGHLY.
400472 - SWALLOWING PATTERN IS NOT LIKELY TO CHANGE MUCH BECAUSE OF
400473 - THE ANATOMY OF YOUR ESOPHAGUS. SUCCESSFUL DILATION BUT
400474 - WILL NEED TO REPEAT EXAM IN 3 MONTHS. APPT IS PENDING
400476 - ..
400477 - 3. You may experience some abdominal bloating, cramping or
400478 - gas. Walking around the house or drinking warm weak tea or
400479 - black coffee may help.
400481 - ..
400482 - 4. You might have a mild sore throat following your procedure
400483 - which can be relieved by gargling with warm salt water or
400484 - using throat lozenges.
400486 - ..
400487 - 5. Continue all medications as directed and begin new
400488 - medications as prescribed. YOU MAY START 81 MG ASPIRIN
400489 - ANYTIME NOW. THIS IS NOT CONTRAINDICATED AS LONG AS YOU
400490 - STAY ON OMEPRAZOLE. DO NOT REDUCE THE DOSAGE OF
400491 - OMEPRAZOLE. IT SHOULD REMAIN AT 40MG/DAILY.
400493 - ..
400494 - 6. YOU MAY START aspirin AT ANY TIME, AS PRESCRIBED BY YOUR
400495 - CARDIOLOGIST.
400496 -
400497 - 7. **** missing from VA sequence ****
400499 - ..
400500 - 8. If you have any of the following symptoms, please call the
400501 - clinic checked below for advice.
400502 -
400503 - A. Passing or vomiting a large amount of blood.
400504 - B. Passing black or tarry stools.
400505 - C. Fever over 100 degrees accompanied or not accompanied
400506 - by chills.
400507 - D. Severe inflammation at the needle puncture site.
400508 - E. Severe abdominal or chest pain.
400509 - F. Shortness of breath or tightness in your chest.
400510 - G. Loss of consciousness of frequent bouts of dizziness.
400512 - ..
400513 - Please contact the Martinez Clinic between the hours of
400514 - 8:00 AM to 4:30 PM Monday through Friday for non-urgent
400515 - issues at (925) 372-2000 extension 5168.
400517 - ..
400518 - After 4:30 PM, weekends and holidays, please call the
400519 - advice nurse at (800) 382-8387 for urgent questions. If
400520 - you feel this is an emergency, please go to the nearest
400521 - hospital or dial 911.
400523 - ..
400524 - 9. Additional instructions: (i.e. Sitz Bath, Medications,
400525 - etc.):**
400527 - ..
400528 - 10. Follow Up with: GI Clinic Date: DATE/TIME OF FU
400529 - EGD/DILATION IS PENDING--3 MONTHS--PT REQUESTS THE AM
400531 - ..
400532 - 11. /es/Marcia A Bakerjian, RN
400533 - OR/Recovery Room
400534 - Signed: 04/29/2011 16:58
400535 -
400537 - ..
400538 - Medical Records Procedure 110429 Images Filed Separately Vista
400539 - 110429 Medical Records Procedure Images Filed Separately Vista
400540 -
400541 -
400542 - 2. LOCAL TITLE: PACU Record
400543 - STANDARD TITLE: NURSING RECOVERY ROOM NOTE
400544 - DATE OF NOTE: APR 29, 2011@15:52 ENTRY DATE: APR 29, 2011@16:52:21
400545 - AUTHOR: BAKERJIAN,MARCIA A EXP COSIGNER:
400546 - URGENCY: STATUS: COMPLETED
400548 - ..
400549 - This document contains a scanned Surgery flowsheet. Please
400550 - check VistA Imaging for the scanned document.
400552 - ..
400553 - Administrative Closure: 04/29/2011
400554 -
400555 - by: PICIS IMAGING GENERIC-PICIS
400556 -
400557 -
400558 -
400560 - ..
400561 - Medical Records Progress Notes Procedure 110429
400562 - GI Pre-Proc Proivider Assessment Note 60440 110429
400563 - 110429 GI Pre-Proc Proivider Assessment Note 60440
400564 -
400565 -
400566 - 3. LOCAL TITLE: GI Pre-Proc Provider Assmnt 60440
400567 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
400568 - DATE OF NOTE: APR 29, 2011@12:30 ENTRY DATE: APR 29, 2011@14:43:31
400569 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
400570 - URGENCY: STATUS: COMPLETED
400572 - ..
400573 - *** GI Pre-Proc Provider Assmnt 60440 Has ADDENDA ***,
400574 - (...see below... ref SDS 0 597I)
400576 - ..
400577 - Diagnosis: esophageal stricture
400578 - Scheduled Procedure: egd dilation
400580 - ..
400581 - 1. Reason for the planned procedure: therapy
400583 - ..
400584 - 2. MD/DENTIST/NP ASSESSMENT:
400585 -
400586 - 1. PATIENT HISTORY:
400587 -
400588 - 1. NEURO:
400589 -
400590 - 1. Stroke/Encephalopathy: no
400592 - ..
400593 - 2. AIRWAY:
400594 -
400595 - 1. Prior problems with intubation: no
400596 - 2. Recent stridor/snoring: no
400597 - 3. Other:
400599 - ..
400600 - 3. RESP:
400601 -
400602 - 1. Chronic Bronchitis/Emphysema: no
400603 - 2. Asthma: no
400604 - 3. Recent Infections: no
400605 - 4. Other:
400607 - ..
400608 - 4. INFECTIOUS DISEASE:
400609 -
400610 - AIDS/Hepatitis: no
400612 - ..
400613 - 5. GI/GU:
400614 -
400615 - 1. Kidney Disease: no
400616 - 2. Liver Disease: no
400618 - ..
400619 - 6. CV:
400620 -
400621 - 1. HTN: no
400622 - 2. MI/Angina: yes
400623 - 3. CHF: no
400624 - 4. AICD/Pacemaker: no
400625 - 5. Prosthetic Heart Valve: no
400627 - ..
400628 - 7. OTHER:
400629 -
400630 - 1. Smoking: no
400631 - 2. ETOH: no
400632 - 3. Comments:
400633 -
400635 - ..
400636 - 3. PHYSICAL ASSESSMENT:
400637 -
400638 - 1. Vitals - most recent
400639 -
400640 - 1. Temp:97.5 F [36.4 C] (04/29/2011 13:18)
400641 - 2. BP: 116/75 (04/29/2011 13:18)
400642 - 3. HR: 89 (04/29/2011 13:18)
400643 - 4. RR: 18 (04/29/2011 13:18)
400644 - 5. WT: 200 lb [90.9 kg] (04/29/2011 13:18)
400645 - 6. HT: 66 in [167.6 cm] (04/29/2011 13:18)
400647 - ..
400648 - 2. Allergies: Patient has answered NKA
400650 - ..
400651 - 3. Mental Status: Alert and Oriented x3
400653 - ..
400654 - 4. Airway: Can patient open mouth wide? yes
400655 -
400656 - Can patient stick out tongue? yes
400658 - ..
400659 - Comments:
400661 - ..
400662 - 5. Lung: Comments: Lungs clear
400664 - ..
400665 - 6. Heart: Comments: Heart is regular and no murmur
400667 - ..
400668 - 7. Exam specific to procedure: Comments: Abdomen is soft,
400669 - unremarkable, and no masses felt
400671 - ..
400672 - 8. Medications: Active Outpatient Medications (excluding
400673 - Supplies):
400674 -
400676 - ..
400677 - 4. Active Outpatient Medications
400678 -
400679 - 1. OMEPRAZOLE 20MG EC CAP TAKE TWO CAPSULES BY MOUTH TWICE
400680 - A DAY 15 MINUTES BEFORE A MEAL FOR SEVERE ACID REFLUX
400681 - AND ESOPHAGEAL NARROWING. **DOSE INCREASE**
400683 - ..
400684 - Status.............................. Active
400686 - ..
400687 - 2. SIMVASTATIN 80MG TAB TAKE ONE-HALF TABLET BY MOUTH
400688 - EVERY EVENING - FOR CHOLESTEROL*USE PILL CUTTER* DO
400689 - NOT TAKE WITH GRAPEFRUIT JUICE.
400691 - ..
400692 - Status.............................. Active
400694 - ..
400695 - 5. Is new EKG or CXR Necessary: no
400697 - ..
400698 - 6. Pertinent Lab data:
400700 - ..
400701 - 7. American Society of Anesthesiologist (ASA) Classification:
400702 - 2
400704 - ..
400705 - 8. RE-EVALUATION Prior to Procedure - To be completed by
400706 - Procedure MD/Dentist at the time of procedure.
400708 - ..
400709 - 9. I have reviewed the interim history and repeated the
400710 - relevant physical exam. There are no significant changes
400711 - compared to prior visit.
400713 - ..
400714 - 10. SEDATION PLAN:
400715 -
400716 - 1. Sedation/Anesthesia options, benefits, and risks were
400717 - discussed including: nausea/vomiting, allergic
400718 - reactions, unexpected cardiac or pulmonary problems,
400719 - and cardiac arrest.
400721 - ..
400722 - 2. Patient expressed understanding and wishes to proceed
400723 - with planned sedation/anesthesia.
400725 - ..
400726 - 3. Did a family member or companion accompany the patient
400727 - and participate in the discussion and Interview? no
400729 - ..
400730 - 4. Procedure can proceed with sedation.
400732 - ..
400733 - 5. Sedation Plan: Moderate
400734 -
400735 - 11. /es/ RANDALL E LEE, MD
400736 - STAFF PHYSICIAN, GASTROENTEROLOGY
400737 - Signed: 04/29/2011 14:44
400739 - ..
400740 - 12. 04/29/2011 ADDENDUM STATUS: COMPLETED
400741 -
400742 - egd & tts dilation 152026 dictated: dilated to 16.5mm
400743 -
400744 - 13. /es/ RANDALL E LEE, MD
400745 - STAFF PHYSICIAN, GASTROENTEROLOGY
400746 - Signed: 04/29/2011 16:12
400747 -
400748 -
400750 - ..
400751 - Medical Records Informed Consent EGD Procedure and Sedation 110429
400752 - Informed Consent EGD Procedure and Sedation 110429 Medical Records
400753 - Sedation and EGD Procedure Informed Consent 110429 Medical Records
400754 - 110429 Informed Consent EGD Procedure and Sedation Medical Records
400755 -
400756 - Follow up ref SDS 72 JT7N.
400757 -
400758 - Doctor's Progress Notes were corrupted in PDF file received from VA,
400759 - so not entered in the record here, but this is availabe...
400761 - ..
400762 - 4. LOCAL TITLE: Informed Consent 20303
400763 - STANDARD TITLE: PROCEDURE CONSENT
400764 - DATE OF NOTE: APR 29, 2011@14:42:12 ENTRY DATE: APR 29, 2011@14:43:02
400765 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
400766 - URGENCY: STATUS: COMPLETED
400768 - ..
400769 - Signature Informed Consent for EGD WITH POSSIBLE INTERVENTIONS
400770 - (VA) (ESOPHAGOGASTRODUODENOSCOPY (EGD) WITH POSSIBLE
400771 - INTERVENTIONS) ESOPHAGEAL DILATION MODERATE SEDATION WITH
400772 - ANALGESIA - COMBINE WITH OTHER PROCEDURE
400773 -
400774 - 1. Anatomical Location: egd with dilitation
400776 - ..
400777 - 2. Informed consent was obtained at 2:42 PM on April 29, 2011.
400778 - The full consent document can be accessed through Vista
400779 - Imaging.
400781 - ..
400782 - 3. Patient name: WELCH, RODNEY CHARLES
400784 - ..
400785 - 4. The patient HAS decision-making capacity.
400787 - ..
400788 - 5. Surrogate (if applicable):
400790 - ..
400791 - 6. Reason for the treatment (diagnosis, condition, or
400792 - indication): To examine and treat the esophagus, stomach,
400793 - and first part of small intestine for abnormalities and
400794 - disease. Esophageal dilation is performed when a patient
400795 - has a partially or totally closed portion of the esophagus
400796 - (the long tube between the throat and the stomach).
400797 - Possible anxiety or discomfort during medical procedure.
400799 - ..
400800 - 7. Treatment/procedure: ESOPHAGOGASTRODUODENOSCOPY (EGD)
400801 - WITH
400802 -
400803 - 1. POSSIBLE INTERVENTIONS
400804 -
400805 - Upper GI endoscopy or esophagogastroduodenoscopy (EGD)
400806 - is a procedure to look at and treat problems in your
400807 - esophagus (swallowing tube), stomach, and first part of
400808 - your small intestine (duodenum). A flexible, steerable
400809 - tube (endoscope) will be used. This tube has a light,
400810 - camera and openings for tools. Before the procedure
400811 - starts, your throat may be sprayed with some numbing
400812 - medication. After that, you may be given medicine to
400813 - make you sleepy (sedation). After you are sleepy, the
400814 - tube will be passed through your mouth and into your
400815 - esophagus, stomach, and duodenum. Several things can
400816 - be done with the endoscope, depending on what is found.
400817 - These include:
400818 -
400819 - 1. Take photographs.
400820 - 2. Remove samples of tissue (biopsies).
400821 - 3. Remove growths.
400822 - 4. Control or prevent bleeding by injecting
400823 - medicines, applying heat
400824 - (cautery) or placing clips or rubber bands.
400825 - 5. Stretch narrow areas with balloons or tapered
400826 - plastic dilators.
400827 - 6. Other things the doctor thinks are necessary.
400829 - ..
400830 - 2. ESOPHAGEAL DILATION
400831 -
400832 - 1. The goal of this procedure is to reopen a blockage
400833 - or stricture (narrowing) in the esophagus.
400835 - ..
400836 - 2. Esophageal dilation may be performed directly using
400837 - a bougie (a flexible, cylindrical instrument used
400838 - to dilate narrowed areas) or an endoscope (a
400839 - tube-like tool used to look inside the body that
400840 - often has channels to pass other tools through).
400842 - ..
400843 - 3. A simple "bougie dilation" may be done in a doctor's
400844 - office.
400846 - ..
400847 - 4. With the patient sitting up, the doctor sprays
400848 - anesthetic on the back of the throat to numb the
400849 - area.
400851 - ..
400852 - 5. The bougie is then guided to the stricture and used
400853 - to push against the wall of the esophagus,
400854 - stretching it to the desired width.
400856 - ..
400857 - 6. An endoscopic procedure is performed in an
400858 - endoscopy suite, either at a clinic or hospital.
400860 - ..
400861 - 7. Fluoroscopy, a real-time x-ray, may be used during
400862 - this procedure. It helps the doctor view your
400863 - organs.
400865 - ..
400866 - 8. During the dilation, the patient lies face up and
400867 - is sometimes given a sedative (medication to help.
400868 - An endoscope is placed into the esophagus. When
400869 - the blockage is reached, the doctor inserts a
400870 - flexible wire across the stricture and attempts to
400871 - open it.
400873 - ..
400874 - 9. A dilator is then used to widen the narrowed area.
400875 - Several successively larger dilators may be used
400876 - until the desired amount of dilation is achieved.
400878 - ..
400879 - 10. Dilation using a balloon may be performed for
400880 - patients with aclasia.
400882 - ..
400883 - 11. This is usually done with x-ray guidance to ensure
400884 - that the balloon is properly placed at the
400885 - stricture site.
400887 - ..
400888 - 12. When the balloon is inflated, it stretches and
400889 - breaks the spastic muscle fibers that are causing
400890 - the constriction.
400892 - ..
400893 - 3. MODERATE SEDATION WITH ANALGESIA - COMBINE WITH OTHER
400894 - PROCEDURE
400895 -
400896 - 1. This procedure involves using drugs to cause deep
400897 - relaxation. Your doctor or nurse will give the
400898 - medicine intravenously. 'Intravenously' means
400899 - 'inside a vein'.
400901 - ..
400902 - 2. You will still be able to hear and respond to
400903 - commands. Your lungs and heart will function
400904 - normally. The drugs may keep you from remembering
400905 - all or part of the procedure.
400907 - ..
400908 - 3. ESOPHAGOGASTRODUODENOSCOPY (EGD) WITH POSSIBLE
400909 - INTERVENTIONS ESOPHAGEAL DILATION
400911 - ..
400912 - 8. Moderate sedation will be used.
400913 -
400914 - 1. Medications will be administered to decrease anxiety
400915 - and discomfort during the treatment/procedure.
400916 -
400917 - 2. These medications will be administered by a
400918 - qualified practitioner.
400920 - ..
400921 - 3. Patient response to some of these medications varies.
400922 - Patients are expected to remain aware and responsive
400923 - during the treatment or procedure.
400925 - ..
400926 - 4. Minor risks of moderate sedation include temporary
400927 - amnesia or forgetfulness and drowsiness.
400929 - ..
400930 - 5. Moderate sedation can interfere with your ability to
400931 - drive, operate machinery, or make important decisions
400932 - for up to 24 hours.
400934 - ..
400935 - 6. Medications used for moderate sedation can cause
400936 - allergic reactions, respiratory depression (this is
400937 - when your breathing slows down and may stop), low blood
400938 - pressure, and a slow or irregular heart beat.
400940 - ..
400941 - 7. In rare instances these complications can cause death.
400943 - ..
400944 - 8. Tell your health care team if you do not want to
400945 - receive moderate sedation.
400947 - ..
400948 - 9. Consent to Blood Products (if applicable):
400949 -
400950 - 1. I CONSENT to the use of blood products during this
400951 - treatment/procedure if they are needed to improve my
400952 - overall condition or save my life.
400954 - ..
400955 - 2. I understand that my consent for use of blood products
400956 - is valid while I recover from the treatment/procedure.
400958 - ..
400959 - 3. My provider will determine when this recovery period
400960 - ends.
400962 - ..
400963 - 4. If this consent form expires, my treatment plan
400964 - changes, or if blood products are needed for a reason
400965 - that is unrelated to this treatment/procedure, I will
400966 - be asked again for my consent for use of blood
400967 - products.
400969 - ..
400970 - 5. I understand that common risks of using blood products
400971 - include (but are not limited to) infection or
400972 - irritation where the needle is placed, fever, chills,
400973 - and skin rashes.
400975 - ..
400976 - 6. Other rare but more serious complications may occur
400977 - such as allergic reactions, heart failure due to fluid
400978 - overload, acute pulmonary edema (fluid leaking into the
400979 - lungs), shock, or death.
400981 - ..
400982 - 7. I also understand that transfusions of blood or blood
400983 - products involve a small risk of transmission of
400984 - diseases such as Hepatitis B (1 in 137,000), Hepatitis
400985 - C (1 in 1,000,000), and HIV/AIDS (1 in 1,900,000).
400987 - ..
400988 - 8. There is also a small risk of bacterial infection when
400989 - blood platelets are transfused.
400991 - ..
400992 - 9. Alternatives to blood or blood products may be
400993 - available if my health, time, and procedure permit.
400995 - ..
400996 - 10. These alternatives may include auto-donation (using my
400997 - own previously donated blood) and intra-operative
400998 - salvage (my own blood collected during surgery). In
400999 - addition, medications may be used to reduce the need
401000 - for blood products.
401002 - ..
401003 - 10. Practitioner obtaining consent: Lee,Randall E (STAFF
401004 - PHYSICIAN)
401006 - ..
401007 - 11. Supervising practitioner:
401009 - ..
401010 - 12. Practitioner(s) performing or supervising
401011 - treatment/procedure (if not listed above):
401013 - ..
401014 - 13. Witness Name(s):
401016 - ..
401017 - 14. Comments:
401018 -
401019 -
401020 -
401021 -
401022 -
401023 -
401024 -
401025 -
401026 -
401027 -
401028 -
401029 -
4011 -