CONTACTS
SUBJECTS
VA EGD Procedure Dilate Stricture Lower Esophageal Sphincter Valve L
3603 -
3603 - ..
3604 - Summary/Objective
3605 -
360501 - Follow up ref SDS 77 0000. ref SDS 72 0000.
360502 -
360503 -
360504 -
360506 - ..
3606 -
3607 -
3608 - Background
3609 -
360901 - On 101210 EGD procedure dilated esophageal sphincter valve from 11 to
360902 - 14 mm. EGD today dilate from 14 to 17 mm. ref SDS 66 BF6L
360904 - ..
360905 - Test today was schedule in VA's letter dated 101210, received on
360906 - 101214 2330. ref SDS 68 ZG7O
360908 - ..
360909 - On 101216 1021 letter commends medical team for excellent work, and
360910 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
360912 - ..
360913 - On 110218 0730 4th EGD dilation at VA in Martinez, 110218 0730,
360914 - ref SDS 72 SR8M, and using anesthesia with Fentanyl. ref SDS 72 SR5O
360916 - ..
360917 - On 110429 0830 5th EGD dilation at VA in Martinez, 110429 1230,
360918 - ref SDS 77 NU8L, and using anesthesia with Fentanyl. ref SDS 77 SR5O
360919 - Good results dilating stricture in LESV to "ring finger," Next EDG
360920 - dilation ordered in 3 months, on 110729 0730. ref SDS 77 LJ6J
360922 - ..
360923 - On 110607 1414 visited GI Department, ref SDS 81 HC5H, and Charlene
360924 - reported a computer mistakes requires scheduling next EGD dilation on
360925 - 110819 0830. ref SDS 81 N642 Requested meeting with Doctor Lee, and
360926 - for the purpose of reviewing pending action items. ref SDS 81 4P6J,
360928 - ..
360929 - 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter
360930 - valve. ref SDS 0 K37G
360931 -
360932 -
360934 - ..
3610 -
3611 -
3612 - Progress
3613 -
361301 - Rosuvastatin Cholesterol Prescription at VA Pharmacy Interim Amount
361302 -
361303 - Follow up ref SDS 77 K37G, ref SDS 70 9P83.
361304 -
361305 - Kathy drove from Sacramento and stayed over last night for
361306 - transportation to VA required to perform EGD and dilation procedure
361307 - today, and with anesthesia, planned on 110607 1414. ref SDS 81 N642
361309 - ..
361310 - During EGD/Dilation, Kathy borrowed VA card and went to Pharmacy on
361311 - ground floor to get rosuvastatin, planned during call yesterday on
361312 - 110818 1051. ref SDS 85 FI6G
361314 - ..
361315 - After arriving home, investigation shows there is only enough
361316 - medication for 2 weeks.
361318 - ..
361319 - Will check on Monday to get enough for 3 weeks.
361321 - ..
361322 - Another possibility is that the full prescription will be received
361323 - in the mail by next Tuesday, before leaving for New York.
361325 - ..
361326 - Could continue taking simvastatin for next week, and then start
361327 - rosuvastatin; or could start rosuvastatin immediately, and then either
361328 - stop treatment for a week, or take simvastatin for the 3rd week.
361329 -
361330 -
361331 -
361333 - ..
361334 - GI Department Arrive for EGD Dilation Administration
361335 -
361336 - Follow up ref SDS 77 NU8L.
361337 -
361338 - Checked in to GI Department at 0814.
361340 - ..
361341 - Prepared patient history questionaire for the procedure.
361343 - ..
361344 - Submitted Kathy's cell phone for designated driver.
361347 -
361348 -
361349 -
3614 -
SUBJECTS
Default Null Subject Account for Blank Record
3703 -
3704 - 1123
370501 - ..
370502 - Medical Records Ordered for Case Management
370503 -
370504 - Follow up ref SDS 77 4U55.
370505 -
370506 - Forgot to order medical records after the procedure. Was a little
370507 - groggy from sedation.
370508 -
370509 - [On 110823 1158 received medical chart for everything
370510 - except work today on 110819, because the doctor has not had
370511 - time to enter the record. ref SDS 86 469G
370513 - ..
370514 - [On 110912 1008 called Wilma about getting medical record
370515 - for work on 110819. ref SDS 87 125O
370516 -
370517 -
370519 - ..
3706 -
3707 -
3708 - 1218
3709 -
370901 - We went to lunch at the Buttercup on Clayton and Treat, and then came
370902 - home and began entering the record, per below. ref SDS 0 SR8M
370903 -
370910 - ..
370911 - While at home entering the record for work today, Kathy recalled we
370912 - did not stop at ROI to see Wilma for ordering the medical chart on
370913 - work at the VA the past month.
370915 - ..
370916 - Called Wilma and asked if she might be able to prepare medical
370917 - records on a CD in time to leave town next Tuesday on 110823.
370919 - ..
370920 - Wilma said will try.
370922 - ..
370923 - Kathy drove us back to the VA.
370924 -
370926 - ..
3710 -
3711 -
3712 - 1348
3713 -
371301 - We went to Release of Information (ROI) Department on the 2nd floor
371302 - and met with Wilma. Filled out form requesting medical chart for...
371303 -
371304 - 1. Lab............................ 110727 1238, ref SDS 82 RP4N
371305 - 2. Meeting Doctor Sandhu.......... 110803 1400, ref SDS 83 PP8W
371306 - 3. Meeting Doctor Egan............ 110817 1030, ref SDS 84 JE5I
371307 - 4. Meeting Doctor Lee............. 110819 0830, ref SDS 0 SR8M
371308 -
371309 -
371310 -
371311 -
371312 -
3714 -
SUBJECTS
Default Null Subject Account for Blank Record
3803 -
3804 - 0852
380501 - ..
380502 - Signature Requested Blank Form on Understanding Discharge Instructions
380503 -
380504 - Follow up ref SDS 77 SR8M.
380505 -
380506 - Iris called patient into pre-op, took vitals, and set a catheter to
380507 - inject anesthesthetic for conscious sedation, used later in the OR,
380508 - per below. ref SDS 0 SR5O
380510 - ..
380511 - Iris provided a document for signature...
380512 -
380513 - GI Discharge Instructions
380515 - ..
380516 - This document has no instructions, and no date nor time is entered.
380517 - Asked for clarification that the VA wants the patient to sign a blank
380518 - form?
380520 - ..
380521 - Iris confirmed explanation for prior procedure on 110429 1230.
380522 - ref SDS 77 IT7G
380524 - ..
380525 - [...below after the procedure, received in Recovery
380526 - Discharge form, signed in blank form before the procedure,
380527 - filled out in Recovery, ref SDS 77 ZI87; questions pending
380528 - on measurements from examination findings, ref SDS 77 538L,
380529 - and dose for Omeprazole medicaition. ref SDS 77 6Q4H
380530 -
380531 -
3806 -
SUBJECTS
Default Null Subject Account for Blank Record
3903 -
390401 - ..
390402 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
390403 -
390404 - Follow up ref SDS 77 UN6K.
390405 -
390406 - Asked if Tunisia is working today, and can she do the IV, per
390407 - experience for prior procedure, when she was successful after others
390408 - had difficulty setting IV. 110429 1230, ref SDS 77 D95L
390410 - ..
390411 - Iris said that Tunisia is no longer working at the VA Martinez clinic.
390413 - ..
390414 - Iris was successful on 1st try getting blood flow for the IV needed
390415 - to provide sedation.
390417 - ..
390418 - This corrects prior problems reported in study on 110429 1230.
390419 - ref SDS 77 UN6K
390421 - ..
390422 - After getting documentation entered in computer, Iris facilitated
390423 - weigh in down the hall - weight 192.
390424 -
390425 - [On 110823 1158 weigh in 189 in Primary Care.
390426 - ref SDS 86 125O
390427 -
390428 -
390429 -
390430 -
3905 -
SUBJECTS
Default Null Subject Account for Blank Record
4003 -
4004 - 0913
400501 - ..
400502 - Consent Signed Continue Dilation Improve Swallowing
400503 -
400504 - Follow up ref SDS 77 SR4G.
400506 - ..
400507 - Visited with Kendal before Doctor Lee arrived.
400509 - ..
400510 - Advised that have never had stomach pain often called "heart burn,"
400511 - and so asked how this aligns with getting treatment with Omeprazole?
400513 - ..
400514 - Kendal explained that patients can suffer stomach acid problems
400515 - without feeling discomfort or any symptoms. Evidence of stomach acid
400516 - in this case is evident from continuing stricture in LESV.
400518 - ..
400519 - Kendal also advised that average healthy LESV diameter is 20 mm.
400521 - ..
400522 - He recalled that the doctor dilated the stricture to 16.5 mm for the
400523 - prior procedure on 110429. Record is unclear; on 110429 doctor
400524 - advised LESV dilated to size of "ring finger." ref SDS 77 SS5R
400525 - Medical chart reviewed later indicates 18 mm, shown in record on
400526 - 110520 1537, ref SDS 79 QO4I; addendum filed at end of medical chart
400527 - says 16.5 mm. ref SDS 79 LX5I
400529 - ..
400530 - He seemed further to say that normally, the doctor does not dilate
400531 - to 20 mm. The reason was unclear during this discussion.
400532 -
400534 - ..
4006 -
4007 -
4008 - 0932
4009 -
400901 - Doctor Lee arrives. Shook hands. Signed consent for the procedure.
400903 - ..
400904 - Doctor Lee clarified that Omperazole should be taken twice a day
400905 - regardless of eating meals.
400907 - ..
400908 - Asked about report by Ray at the front desk, that Doctor Lee is
400909 - leaving the VA practice at the end of this month?
400911 - ..
400912 - Doctor Lee said he will continue seeing patients at VA Clinic in
400913 - Martinez until December, so we can do the next procedure here
400914 - scheduled for November, planned by Charlene on 110607 1414.
400915 - ref SDS 81 NG52
400917 - ..
400918 - After November, the doctor will only treat patients at the VA Medical
400919 - Center in Sacramento.
400921 - ..
400922 - The doctor left to continue work with other patients.
400923 -
400924 -
400925 -
400927 - ..
4010 -
4011 -
4012 - 1002
4013 -
401301 - Kendall walked patient into OR.
401302 -
401303 - In the OR, Kendall was assisted by Tom, who again remembered me from
401304 - prior work on 101210 0930. ref SDS 66 IR4J
401306 - ..
401307 - Tom applied Lidocaine to numb the throat, using an instrument with a
401308 - long tube to squirt the back of the throat, gargel and then swallow
401309 - the Lidocaine. This is done twice, once on each side of the throat,
401310 - and set out in the record for the last procedure on 110429 1230.
401311 - ref SDS 77 UO6L
401313 - ..
401314 - Kendal connected sedation injections into the IV, starting with
401315 - Fentynal.
401316 -
401317 -
401318 -
401319 -
401320 -
4014 -
SUBJECTS
Default Null Subject Account for Blank Record
4103 -
410401 - ..
410402 - Chronic Swallowing Requires Dilation Conflicts Objectives Surgery
410403 - Quality Care Review Heller Myotomy Surgery Align Results with Objectives
410404 -
410405 - Follow up ref SDS 77 QF6L.
410406 -
410407 - When Doctor Lee entered the OR, we discussed Doctor Egan's work plan
410408 - to add aspirin to the list of medications, and for the purpose of
410409 - preventing blood clots (thrombus, emoblism) that cause complications
410410 - for CAD, including death, reported on 110415 0900. ref SDS 75 UR7L VA
410411 - medical chart for work in Primary Care says in part that aspirin
410412 - presents risks of gastric ulcers and bleeding, reported on 101223
410413 - 1030. ref SDS 70 454F
410414 -
410416 - ..
410417 - Doctgor Lee asked about results from prior dilation on 110218 0730?
410418 - ref SDS 72 EU9G Kendall asked if there is a feeling of food stuck in
410419 - the esophagus at the moment?
410421 - ..
410422 - Reported immediate feeling of minor congestion in the throat from
410423 - eating dinner yesterday on Thursday evening 110428 about 1700,
410424 - reported in case study on 101010 0744. ref SDS 52 O48F Asked the team
410425 - to write in the medical chart actual findings today, when the doctor
410426 - accesses the throat using a camera to make direct examination of
410427 - current conditions for EGD.
410429 - ..
410430 - Asked about occassional horseness talking in meetings and calls. For
410431 - example today in the OR laying on the table and talking to the team
410432 - the voice seems somewhat raspy.
410434 - ..
410435 - Doctor Lee advised that raspy voice is associated with chronic throat
410436 - congestion from incomplete swallowing.
410438 - ..
410439 - The doctor explained swallowing problems originally diagnosed as
410440 - achalasia, reported on 051202 1430. ref SDS 3 5B5K, now occur from
410441 - acid burn causing a "stricture" at the same location on the lower
410442 - esophageal sphincter valve, which reduces the size of the valve for
410443 - passing food into the stomach. The symptom is identical though
410444 - reduced in degree from achalasia treated beginning on 051202 1430.
410445 - ref SDS 3 5B5K
410446 -
410447 - [...below after EGD dilation procedure, discharge
410448 - documentation shows doctor's handwritten diagram of LESV,
410449 - with notation of "narrow area," aligns with explanation
410450 - during meeting that "stricture" in the medical chart refers
410451 - to LESV. ref SDS 77 949J
410453 - ..
410454 - Reported continued significantly improved swallowing after EGD
410455 - dilation from 11 to 14 mm on 101210, of lower esophageal sphincter
410456 - valve (LESV), beginning on 101211, and from prior follow up EGD and
410457 - dilation from 11 to 14 mm, reported on 110218 0730. ref SDS 72 SS5R
410458 - Continued improved swallowing from 110219, is shown in case study on
410459 - 101010 0744. ref SDS 52 IN7K
410461 - ..
410462 - Doctor Lee asked if there have been any vomitting episodes since
410463 - treatment on 110218, when the lower esophageal sphincter valve, also
410464 - called a "stricture," in the medical chart, was dilated to 14 mm.
410466 - ..
410467 - On the OR table recalled 2 events.
410469 - ..
410470 - On 110330, vomitted nearly all of a patty melt (hamburger) sandwich,
410471 - reported in case study on 101010 0744. ref SDS 52 7Q8I A few weeks
410472 - later on 110417, same occurred after eating a corned beef (Reuben)
410473 - sandwich. ref SDS 52 QZ5K
410475 - ..
410476 - We reviewed the record meeting with Doctor Stewart at the VA Medical
410477 - Center in San Francisco. On 091030, The doctor presented a work plan
410478 - to perform Heller Myotomy surgery for comprehensive recovery from
410479 - achalasia, which was intended to replace treatment with pneumatic
410480 - dilation. ref SDS 19 P69G The VA's work plan was approved, and work
410481 - was performed on 091216 0600. ref SDS 31 KE9U Subsequently, beginning
410482 - on 100305, VA has performed 5 pneumatic dilations required to restore
410483 - swallowing. This record indicates care for a chronic condition,
410484 - planned to be obviated by approving surgery at the Medical Center.
410485 -
410486 -
410488 - ..
410489 - Medical Records Access Problematic for Timely Health Care Decisions
410490 -
410491 - Follow up ref SDS 77 EK5J.
410492 -
410493 - Kendhal used a computer in the OR at the VA Clinic in Martinez, to
410494 - find the record of Heller Myotomy surgery at the Medical Center in San
410495 - Francisco. He reported finding no record of Doctor Stewart's surgery,
410496 - and asked for the date of the work?
410498 - ..
410499 - Difficulty finding medical records was previously reported by Doctor
410500 - Brzezinski in the OR, and while preparing the work plan for anesthesia
410501 - to support heart surgery at the VA Medical Center in San Francisco on
410502 - 091022 0700. ref SDS 16 JF9K Last year the VA was cited for
410503 - increasing access to medical records on the computer, reported on
410504 - 100911 0800. ref SDS 50 OL50
410506 - ..
410507 - Advised that Doctor Stewart and her team did the work on 091216.
410508 - 091216 0600, ref SDS 31 KE9U
410510 - ..
410511 - Kendall said the medical chart for 091216, is not showing up today on
410512 - the computer in the OR at the VA Clinic in Martinez.
410514 - ..
410515 - Though Kendall could not display the record of surgery to recover from
410516 - Achalasia on 091216, on the computer in the OR, Doctor Lee seemed to
410517 - recall seeing the record sometime earlier. He feels his examinations
410518 - beginning on 100305, show that surgery on 091216, accomplished VA
410519 - objectives in the medical chart for work on 091216.
410520 -
410521 -
410523 - ..
410524 - Surgery Correlate Results with Objectives Improve Patient Care
410525 -
410526 - Follow up ref SDS 77 HO5H.
410527 -
410528 - The "Operation Report" in the medical chart for work on Achalasia and
410529 - performed at the VA Medical Center in San Francisco on 091216, was
410530 - received from the VA on 100928. ref SDS 51 SO4N
410532 - ..
410533 - The section on Clinical Indications says in part...
410534 -
410535 - Risks, benefits, and alternatives were discussed with the
410536 - patient regarding laparoscopic Heller myotomy and Dor
410537 - fundoplication and after all questions were answered, informed
410538 - consent was obtained. ref DRP 1 SO5F
410540 - ..
410541 - Merely saying "benefits and alternatives were discussed," begs the
410542 - question of what benefits and what alternatives were presented that
410543 - justified approval for surgery.
410545 - ..
410546 - This might be a good time for quality care review of results in
410547 - relation to benefits and alternatives, per above. ref SDS 77 DD4N
410548 - Asked Doctor Lee to adivse procedure for scheduling a meeting with
410549 - Doctor Stewart for follow up. If the scope of surgery on 091216, was
410550 - reduced was reduced from planning on 091030, leading to continuing
410551 - remedial work with pneumatic dilation, might there be additional
410552 - surgery that can provide a comprehensive solution planned in the
410553 - meeting on 091030 0810? ref SDS 19 P69G
410555 - ..
410556 - Doctor Stewart planned to prevent scarring the esophagus by surgically
410557 - constructing a "flap" to prevent backflow from the stomach.
410558 - ref SDS 19 OY64 Since Doctor Lee's work shows acid burn on LESV has
410559 - caused restricted swallowing intended to be solved with Heller Myotomy
410560 - surgery, Doctor Stewart can investigate the flap for alignment with
410561 - planning, and whether additional work can eliminate current problems
410562 - in this case, and/or for other patients.
410564 - ..
410565 - Objectives today are to find elevated treatment wtih Omeprazole has
410566 - been effective reducing acid burn scarring on LESV, which will be
410567 - established by examination finding LESV did not contract again, but
410568 - remains at 14 mm dilated during prior work on 110218 0730. At that
410569 - time, previous dilation on 101210, to 14 mm was found to have
410570 - contracted back to 11 mm on 110218. ref SDS 72 SS5R
410571 -
410572 - [...below Discharge document shows handwriting saying LESV
410573 - dilated to size of "ring finger." ref SDS 77 9498
410575 - ..
410576 - After discussing case management, Kendall gave Fentanyl, and then
410577 - other drugs for conscious sedation, used for anesthetic, reported in
410578 - medical chart for procedure on 100827 0738. ref SDS 49 JE9V
410579 -
410580 -
410582 - ..
4106 -
4107 -
4108 - 1613
4109 -
410901 - Awake in recovery.
410902 -
410903 - Nurse removed IV catheter. The nurse called Kathy on the cell phone
410904 - advising patient can go home.
410906 - ..
410907 - Dressed and met with Doctor Lee.
410909 - ..
410910 - Doctor Lee advised that...
410911 -
410912 - 1. Esophagitis scar formation - Doctor Lee advised that he
410913 - found improvement. There is less infection and acid burn
410914 - since prior examination on 110218. ref SDS 72 EU9G
410915 -
410916 - The doctor presented photographs taken during the procedure
410917 - today and showing esophageal tissue is uniform in natural
410918 - color and texture, indicating reduced disease. The 4
410919 - pictures observed during the meeting seem devoid of any
410920 - medical problems. Pathology report on biopsies taken today
410921 - will further assess esophagitis.
410922 -
410923 - [...below, Discharge documentation shows handwritten
410924 - report saying "Esophagus looked better." ref SDS 77 GP5L
410926 - ..
410927 - [On 110520 1537 photographs missing from medical chart
410928 - received from VA, ref SDS 79 548L, for procedure today
410929 - on 110429. ref SDS 77 MM43
410931 - ..
410932 - [On 110520 1537 medical chart received for work today
410933 - shows no record of biopsies to assess esophagitis
410934 - requirements for elevated dose Omeprazole 80 mg per day.
410935 - ref SDS 79 3V5K
410937 - ..
410938 - 2. Lower esophageal sphinchter valve (LESV) - the doctor
410939 - seemed to say that examination today found less contraction
410940 - than occurred for prior EDG and dilation on 110218 0730.
410941 - ref SDS 72 SS5R He was able to dilate the stricture
410942 - (stenosis) to about the size of the "ring finger." The
410943 - doctor did not say that objective was met to dilate the
410944 - stricture to 17 mm, discussed prior to the procedure, per
410945 - above. ref SDS 77 OW5N
410946 -
410947 - [...below, Discharge documentation shows the doctor
410948 - wrote by hand that stricture was dilated to the size of
410949 - "ring finger." ref SDS 77 9498
410951 - ..
410952 - [On 101010 0744 case study for 110504, vomitting 90%
410953 - likely due to eating too fast, with big bites - big
410954 - mistake, despite report that esophageal stricture was
410955 - dilated on 110429, larger than expected. ref SDS 52 SY8F
410957 - ..
410958 - [On 101010 0744 0% vomitting eating hamburger and fries
410959 - reflects eating slowly and drinking liquid with meal,
410960 - ref SDS 52 Z36H, and notice tody of success dilating
410961 - stricture at LESV to wider diameter, per above.
410962 - ref SDS 77 SS5R
410964 - ..
410965 - Whose ring finger?
410967 - ..
410968 - Patient's ring finger measures about .8 inches above the
410969 - knuckle, where rings are typically worn. This converts to
410970 - 20 mm, significantly exceeding objectives for dilating LESV
410971 - to 17 mm.
410973 - ..
410974 - Need Medical Chart for actual measurements on degree of
410975 - contraction found by examination, and amount dilated. The
410976 - Medical Chart for this work was ordered from Wilma in
410977 - Release of Information Department, prior to starting work
410978 - in GI Department, reported above. ref SDS 77 4U55
410979 -
410980 - [On 110520 1130 received medical chart shows conflicting
410981 - results for dilation, Proc report item #6 seems to say
410982 - dilation was done in 2 stages; first stage from 12 - 15,
410983 - and 2nd stage from 15 - 18, ref SDS 79 QO4I; however, an
410984 - addendum to pre-proc exam item #4 says only 16 mm.
410985 - ref SDS 79 LX5I
410987 - ..
410988 - 3. Steriod injected into the stricture (which is LESV, per
410989 - doctor's diagram in Discharge document shown below,
410990 - ref SDS 77 DU6J) to help prevent contraction again from size
410991 - of "ring finger" dilated today, also, shown in Doctor's
410992 - handwritten notes, below, ref SDS 77 9498, and continuing
410993 - procedure started by the doctor during EGD Dilation on
410994 - 110218 0730. ref SDS 72 SS5N
410995 -
410996 - [On 110819 0830 Progress Notes for EGD Dilation
410997 - procedure today report about 2.5 mL of triamcinolone
410998 - acetate 40 mg/mL was injected into the site of the
410999 - stricture. ref SDS 0 J985
411001 - ..
411002 - [On 111115 1300 the doctor determined in Impressions
411003 - that adding triamcinolone steriod injection to resist
411004 - contraction of LESV was effective to avoid severe
411005 - swallowing and vomitting problems, ref SDS 88 AW6J,
411006 - triamcinolone injection was not performed for the next
411007 - procedure on 111115. ref SDS 88 6H3N
411009 - ..
411010 - 4. Omeprazole dose held at 80 mg per day despite finding
411011 - esophagus looks better, per finding #1 above. ref SDS 77
411012 - MM43
411014 - ..
411015 - Doctor Lee reported having read Doctor Egan's work plan for
411016 - adding aspirin to current regimen of daily medications,
411017 - discussed recently on 110415 0900. ref SDS 75 UR7L
411019 - ..
411020 - The doctor seemed to indicate that Omeprazole even in high
411021 - dose reduces side effects of aspirin. He therefore feels
411022 - there is no conflict taking aspirin with current
411023 - prescription for Omperazole. The doctor did not discuss
411024 - published studies noted by Doctor Egan in the meeting on
411025 - 110415, that indicate conflict between aspirin and low dose
411026 - Ompeprazole 20 mg. ref SDS 75 UR7L
411027 -
411028 - [...below, Discharge documentation shows handwritten
411029 - guidance that seems to say do not change Omeprazole 40
411030 - mg per day, ref SDS 77 6Q4H, and Doctor Lee believes high
411031 - dose Omeprazole 80 mg per day, does not conflict with
411032 - taking low dose aspirin recommended by Doctor Egan for
411033 - cardiology risk management. ref SDS 77 6Q5K
411035 - ..
411036 - 5. EGD procedure scheduled in 3 months during July.
411037 -
411038 - Doctor Lee said that if the VA computer schedules the next
411039 - meeting again in the afternoon, like today, call the VA and
411040 - he will arrange for meeting at 0730, that worked well for
411041 - the prior procedure on 110218 0730. ref SDS 72 K37G
411042 -
411043 - [...above, scheduling next procedure in 3 months, gives
411044 - scarring more time heal so that setting IV catheters is
411045 - easier for the team. ref SDS 77 D95L
411047 - ..
411048 - [...below, Discharge documentation shows doctor's 9th
411049 - handwritten note planning next meeting in 3 months.
411050 - ref SDS 77 GP9I
411052 - ..
411053 - [On 110607 1414 visited Charlene at VA; computer mistake
411054 - prevents following doctor's order to perform next EGD
411055 - dilation on 110729, 3 months after prior procedure,
411056 - ref SDS 81 9Q6V; Charlene scheduled next EGD dilation on
411057 - 110819 0830. ref SDS 81 N642
411058 -
411059 -
411060 -
411061 -
4111 -
SUBJECTS
Default Null Subject Account for Blank Record
4203 -
4204 - 1643
420501 - ..
420502 - GI Discharge Instructions Comprehensive Handwriting Problematic
420503 -
420504 - Follow up ref SDS 77 PR4S, ref SDS 72 PR4S.
420505 -
420506 - Received EGD documentation...
420507 -
420508 - Department Veterans Administration
420509 - VA Northern California Health Care System
420510 - Gastroenterology Department
420512 - ..
420513 - GI Discharge Instructions
420514 -
420515 - 1. Do not drive a motor vehicle, operate machinery or make
420516 - important decisions for at least 24 hours after the procedure.
420517 - The medictions given during the procedure may effect how you
420518 - act and think.
420520 - ..
420521 - 2. You may resume your usual diet after the procedure unless
420522 - instructed otherwise.
420524 - ..
420525 - 3. You may experience some abdominal bloating, cramping or gas.
420526 - Walking around the house or drinking warm weak tea or black
420527 - coffee may help.
420529 - ..
420530 - 4. You might have a mild sore throat following an EGD which can be
420531 - relieved by gargling with warm salt water.
420533 - ..
420534 - Nurse circled #4 with blue ink. Did not notice soreness in the
420535 - throat.
420537 - ..
420538 - Discharge instructions continue...
420539 -
420540 - 5. Continue all medications as directed and begin new medications
420541 - as prescribed.
420542 -
420543 - 6. Do not take aspirin, products containing aspirin, or
420544 - anti-inflammatory agents (i.e., Motrin, Advil, etc) for the
420545 - next *** OK today *** days.
420547 - ..
420548 - Nurse wrote with red ink "OK today" in the blank.
420550 - ..
420551 - Discharge instructions continue...
420552 -
420553 - 7. Warfarin Coumadin Patients
420555 - ..
420556 - Nurse circled #7 and drew a line with blue ink pen through it,
420557 - reflecting patient is not taking these medications.
420559 - ..
420560 - Discharge instructions continue...
420561 -
420562 - 8. If you have any of the following symptoms, please call the
420563 - clinic checked below for advice....
420564 -
420565 - Mon - Fri......................... 925 372 2000 ext 5168
420566 - Weekends Holidays................. 800 382 8387
420567 -
420568 - A. Passing or vomitting a large amount of blood.
420569 - B. Passing black or tarry stools.
420570 - C. Fever over 100 degrees with or without chills.
420572 - ..
420573 - D. Severe inflammation at the needle puncture site.
420575 - ..
420576 - Next day mild inflammation occurred at the two failed IV catheter
420577 - sites, explained above, ref SDS 77 124H, so not severe enough to
420578 - require care. May be "canary in the mine" portending future concern.
420580 - ..
420581 - Discharge instructions continue...
420582 -
420583 - E. Severe abdominal or chest pain.
420584 - F. Shortness of breath or tightness in your chest.
420585 - G. Loss of consciousness or frequent dizziness.
420586 - H. Emergency go to nearest hospital or dial 911.
420588 - ..
420589 - 9. Additional instructions (i.e., Sitz Bath, Medications, etc)
420591 - ..
420592 - There is handwriting with black ink differentiated from blue ink,
420593 - evidently used by the nurse, and presumably entered by the doctor
420594 - showing a medical diagram with handwrtten comments...
420595 -
420596 - | |
420597 - | | Throat
420598 - | |
420599 - | | Lower esophageal sphincter (LES) valve
420600 - ||||||||
420601 - |||||||| <------- narrow area
420602 - / \
420603 - / -----\
420604 - | -\
420605 - | - Stomache
420606 - | |
420607 - / /
420608 - / --------- /
420609 - | /
420610 - \ \
420612 - ..
420613 - The doctor's diagram today, looks similar to the drawing received from
420614 - Doctor Stewart during a meeting at the VA Medical Center in San
420615 - Francisco, and for the purpose of planning Heller Myotomy surgery to
420616 - replace pneumatic dialtion for solving achalasia, reported on 091030
420617 - 0810. ref SDS 19 GM5I
420619 - ..
420620 - The doctor's handwritting in black ink says "narrow area" next to the
420621 - diagram that seems to depict LESV, and so indicates that "stricture"
420622 - entered in the medical chart references LESV is the "narrow area" that
420623 - restricts swallowing, and which was intended to be resolved with
420624 - Heller Myotomy surgery on 091216, Discussion prior to starting EGD
420625 - and dilation procedure, the doctor indicated that surgery solved
420626 - achalasia, but subsequent acid burn caused LESV to swell, thereby
420627 - continuing swallowing problem, per above. ref SDS 77 DD3I
420629 - ..
420630 - Doctor further writes...
420631 -
420632 - 1. Narrow area dilated.
420633 - 2. Opening now the size of ring finger.
420635 - ..
420636 - This seems to relate progress dilating LESV from 14 to 17 mm, assuming
420637 - LESV did not contract back to 11 mm as occurred previously, discussed
420638 - with the doctor prior to starting work, shown above. ref SDS 77 OW5N
420639 -
420640 - [On 101010 0744 case study for 110504, vomitting 90% likely
420641 - due to eating too fast, with big bites - big mistake,
420642 - despite report that esophageal stricture was dilated on
420643 - 110429, larger than expected. ref SDS 52 SY8F
420645 - ..
420646 - [On 101010 0744 0% vomitting eating hamburger and fries
420647 - reflects eating slowly and drinking liquid with meal,
420648 - ref SDS 52 Z36H, and notice tody of success dilating
420649 - stricture at LESV to wider diameter, per above. ref SDS 77
420650 - SS5R
420652 - ..
420653 - Analysis of doctor patient discussion in Recovery post procedure
420654 - indicates patient "ring finger" measures about 20 mm, which exceeds
420655 - objectives for expanding stricture, and notes actual measurements are
420656 - needed in Medical Chart to assess work today. ref SDS 77 SS5R
420658 - ..
420659 - Doctor's handwriting continues...
420660 -
420661 - 3. Small bites will always apply.
420663 - ..
420664 - The doctor's recommendations align with notice in the letter to the
420665 - medical team reporting that swallowing improved with "soft food" and
420666 - eating slowly with plenty of liquid during meals, reported on 110329
420667 - 2213. ref SDS 74 0E3T
420668 -
420669 - [On 101010 0744 case study for 110504, vomitting 90% likely
420670 - due to eating too fast, with big bites - big mistake,
420671 - despite report that esophageal stricture was dilated on
420672 - 110429, larger than expected. ref SDS 52 SY8F
420674 - ..
420675 - Doctor's handwriting continues...
420676 -
420677 - 4. Esophagus looked better.
420679 - ..
420680 - Doctor Lee's comment aligns with doctor/patient post-procedure
420681 - discussion in Recovery, and with photographs that seem to show the
420682 - esophagus has no indications of disease. ref SDS 77 MM43
420684 - ..
420685 - Doctor's handwriting continues...
420686 -
420687 - 5. Swallowing will remain the same (as now).
420689 - ..
420690 - 6. Do not change Omeprazole dose now 40 mg daily.
420692 - ..
420693 - Need clarification on dose for Omeprazole??
420695 - ..
420696 - If the doctor feels Omeprazole 40 mg should be taken daily, this
420697 - changes the prescription for 80 mg daily on 101210 0930. ref SDS 66
420698 - HW8H Medical chart Recommendations entered in section 12 on 101210,
420699 - appear to confirm prescription for taking 80 mg/day. ref SDS 66 5I5H
420701 - ..
420702 - Discharge instructions continue...
420703 -
420704 - 7. Doctor Lee does not see any contradiction to 8/mg
420706 - ..
420707 - 8. Aspirin use = Omeprazole to protect from bleeding side
420708 - effects
420710 - ..
420711 - This seems to align with doctor/patient post-procedure discussion in
420712 - the Recovery room, per above, ref SDS 77 SS8I, and addresses in part
420713 - recent discussion with Doctor Egan on taking aspirn with Omeprazole,
420714 - reported on 110415 0900. ref SDS 75 UR7L
420716 - ..
420717 - Discharge instructions continue...
420718 -
420719 - 9. Next dilation in 3 months.
420721 - ..
420722 - Aligns with doctor/patient post-procedure discussion in recovery room,
420723 - per above. ref SDS 77 LJ6J
420724 -
420725 - [On 110607 1414 visited Charlene at VA; computer mistake
420726 - prevents following doctor's order to perform next EGD
420727 - dilation on 110729, 3 months after prior procedure,
420728 - ref SDS 81 9Q6V; Charlene scheduled next EGD dilation on
420729 - 110819 0830. ref SDS 81 N642
420731 - ..
420732 - Discharge instructions continue...
420733 -
420734 - 10. Follow up with [ ] Primary Care Provider [ ] GI clinic
420735 -
420736 - Nothing is checked in this section, but no follow up required.
420737 -
420738 - Date/Time.....................
420740 - ..
420741 - Discharge document is not dated.
420743 - ..
420744 - Discharge instructions continue...
420745 -
420746 - 11. Nurse Signature
420748 - ..
420749 - This section is illegible.
420751 - ..
420752 - Discharge instructions continue...
420753 -
420754 - 12. Patient's Signature Date/Time
420755 -
420756 - 13. My signature indicates that I understand and have received a
420757 - copy of these instructions.
420759 - ..
420760 - This form was signed before instructions were entered in handwriting,
420761 - set out above, ref SDS 77 DU6J, and noted above reporting VA asked for
420762 - signature on blank form prior to starting work. ref SDS 77 SR8M
420764 - ..
420765 - Discharge instructions continue...
420766 -
420767 - 14. Imprint Patient Data Card (name address social security
420774 - ..
420775 - 15. Medical Record Nursing Documentation
420777 - ..
420778 - 16. VA Form 10-9096
420779 -
420780 -
420781 -
420782 -
421113 - ..
421114 - Posted expense ledger up to date...
421117 -
421118 -
421119 -
421120 -
4212 -
SUBJECTS
Default Null Subject Account for Blank Record
4303 -
430401 - ..
430402 - Progress Notes EGD Dilation Today
430403 -
430404 - Follow up
430405 -
430406 - VA pdf file for these Progress Notes are stored in...
430407 -
430408 - F:\05\00003\SM\CC\AGMJ\20110819-151744\welch_111611.pdf
430410 - ..
430411 - LOCAL TITLE: EGD 60111
430412 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
430413 - DATE OF NOTE: AUG 19, 2011@08:30 ENTRY DATE: AUG 19, 2011@15:17:44
430414 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
430415 - URGENCY: STATUS: COMPLETED
430417 - ..
430418 - PATIENT NAME: WELCH, RODNEY CHARLES
430419 - DATE OF BIRTH: 03/01/1945
430420 -
430421 - 1. PROCEDURE:
430422 -
430423 - 1. Esophagogastroduodenoscopy.
430424 - 2. TTS balloon dilation of esophageal stricture.
430426 - ..
430427 - 2. ATTENDING PHYSICIAN: Randall E. Lee, M.D.
430429 - ..
430430 - 3. INDICATIONS:
430431 -
430432 - 1. Rodney Welch is a 66-year-old man with history of
430433 - achalasia. He underwent laparoscopic myotomy with
430434 - fundoplication at the San Francisco VA in December 2009.
430435 - He did have a distal esophageal stricture believed due to
430436 - GE reflux. EGDs in March, August, December 2010, and
430437 - February, April 2011 showed recurrent strictures between
430438 - endoscopic dilations. Biopsies have shown no evidence of
430439 - malignancy and no evidence of Barrett's esophagus.
430441 - ..
430442 - 2. At the time of his last EGD April 2011, he underwent
430443 - dilation to 16 mm and 3.5 mL of triamcinolone acetate 40
430444 - mg/mL were injected into the stricture.
430446 - ..
430447 - 3. Since then, the patient states that his swallowing has been
430448 - maintained relatively well without major recurrence of
430449 - dysphagia. He has been able to swallow his pills and solid
430450 - food including some hamburger.
430452 - ..
430453 - 4. CONSENT:
430454 -
430455 - The risks, benefits, and alternatives to this procedure
430456 - including, but not limited to the risks of bleeding and bowel
430457 - perforation were explained to the patient. The patient
430458 - understood and provided written informed consent.
430460 - ..
430461 - 5. INTRAVENOUS MEDICATION:
430462 -
430463 - 1. Diphenhydramine 50 mg.
430464 - 2. Fentanyl 200 mcg.
430465 - 3. Midazolam 5 mg.
430467 - ..
430468 - 6. PROCEDURE:
430469 -
430470 - 1. In the Martinez VA GI Endoscopy Unit the patient was placed
430471 - in the left lateral decubitus position. Oxygen at 2 liters
430472 - per minute by nasal cannula was administered.
430473 -
430474 - 2. Continuous oxymetric and hemodynamic monitoring was
430475 - initiated. Intravenous sedation was administered in
430476 - divided doses.
430478 - ..
430479 - 3. After a bite block was placed in the patient's mouth an
430480 - Olympus GIF-Q180 video gastroscope was advanced under
430481 - direct vision into the esophagus.
430483 - ..
430484 - 4. Some retained saliva in the esophagus was easily irrigated
430485 - and suctioned away.
430487 - ..
430488 - 5. At approximately 39 cm was the distal esophageal stricture
430489 - without evidence of mass effect. The endoscope passed
430490 - easily through the stricture and endoscope then advanced
430491 - into the descending duodenum.
430493 - ..
430494 - 6. Retroflexed views of the incisor, fundus, and cardia were
430495 - performed.
430497 - ..
430498 - 7. A TTS balloon dilator was advanced across the stricture and
430499 - inflated to 15 mm. The balloon did not engage at 15 mm and
430500 - the balloon was then inflated to 16.5 mm. This engaged the
430501 - stricture and a small mucosal tear at the level of the
430502 - stricture was noted.
430504 - ..
430505 - 8. Subsequently, about 2.5 mL of triamcinolone acetate 40
430506 - mg/mL was injected into the site of the stricture.
430508 - ..
430509 - This aligns with discussion while meeting with the doctor after the
430510 - procedure today, shown above. ref SDS 0 SS5N
430511 -
430512 - [On 111115 1300 doctor Impressions in Progress Notes for
430513 - next procedure report that adding triamcinolone steriod
430514 - injection to resist contraction of LESV was effective to
430515 - avoid severe swallowing and vomitting problems,
430516 - ref SDS 88 AW6J; yet, for some reason not presented in
430517 - the record triamcinolone injection was not performed on
430518 - 111115. ref SDS 88 6H3N
430520 - ..
430521 - 9. The stomach was decompressed and the gastroscope removed.
430523 - ..
430524 - 7. COMPLICATIONS:
430525 -
430526 - None immediately. The patient tolerated the procedure well.
430528 - ..
430529 - 8. FINDINGS:
430530 -
430531 - 1. Previous area of esophagus tattoo at 34 cm, once again
430532 - without evidence of mass effect.
430533 -
430534 - 2. Esophageal stricture at 39 cm without evidence of
430535 - malignancy that easily passed the diagnostic endoscope
430536 - without trauma.
430538 - ..
430539 - 3. Atonic esophageal body with mildly friable mucosa and only
430540 - retained saliva, but no food contents.
430542 - ..
430543 - 4. Distorted fundus consistent with known fundoplication.
430544 - 5. Mild gastric mucosal erythema.
430545 - 6. Normal pylorus.
430546 - 7. Normal duodenum to D2.
430548 - ..
430549 - 9. IMPRESSION:
430550 -
430551 - 1. Gastroesophageal reflux stricture now appearing to respond
430552 - to combination of proton pump inhibitor therapy, dilation,
430553 - and triamcinolone acetate injection.
430554 -
430555 - 2. Atonic esophageal body with retained esophageal saliva
430556 - consistent with known diagnosis of achalasia. The
430557 - friability of the esophageal body mucosa is significantly
430558 - less compared to the prior examination of April 2011 and
430559 - this may result from improved clearance of the esophagus
430560 - due to relative maintenance of distal esophageal patency.
430562 - ..
430563 - Improved swallowing with less vomitting, may result from injecting
430564 - triamcinolone steriod to maintain dilation of LESV, performed during
430565 - the prior EGD dilation on 110429 1230. ref SDS 77 SS5N
430567 - ..
430568 - Improved results today align with work plan to add triamcinolone
430569 - injections to resist contraction of LESV, reported on 110218 0730.
430570 - ref SDS 72 EN6O
430571 -
430572 - [On 111115 1300 doctor Impressions in Progress Notes for
430573 - next procedure report that adding triamcinolone steriod
430574 - injection to resist contraction of LESV was effective to
430575 - avoid severe swallowing and vomitting problems,
430576 - ref SDS 88 AW6J; yet, for some reason not presented in
430577 - the record triamcinolone injection was not performed on
430578 - 111115. ref SDS 88 6H3N
430580 - ..
430581 - VA Progress Notes continue...
430582 -
430583 - 10. RECOMMENDATIONS:
430584 -
430585 - 1. Continue omeprazole 40 mg twice daily 15 minutes before a meal
430586 - without reduction.
430587 -
430588 - 2. The patient is counseled to remain upright after eating for
430589 - approximately 30 minutes and to continue to wash solid food down with
430590 - liquids.
430591 -
430592 - 3. Repeat EGD with dilation in approximately 3 months on a routine
430593 - basis.
430594 -
430596 - ..
430597 - 11. DISPOSITION:
430598 -
430599 - 1. The patient was observed in the Recovery Room and then discharged
430600 - to home with a companion.
430601 - 2. I reviewed the endoscopic findings with the patient prior to
430602 - discharge.
430603 - 3. The patient once again requests that his next endoscopic
430604 - appointment be scheduled in the morning rather than the afternoon.
430606 - ..
430607 - 12. D: 08/19/2011
430608 - T: 08/19/2011
430610 - ..
430611 - 13. Job number: 855125
430612 - VJJ/CMTS
430613 - $end:
430614 - /es/ RANDALL E LEE, MD
430615 - STAFF PHYSICIAN, GASTROENTEROLOGY
430616 - Signed: 11/08/2011 12:25
430617 -
430618 -
430619 -
430620 -
430621 -
430622 -
430623 -
430624 -
430625 -
430626 -
430627 -
430628 -
430629 -
430630 -
430631 -
430632 -
430633 -
430634 -
430635 -
430636 -
430637 -
430638 -
430639 -
430640 -
430641 -
430642 -
430643 -
430644 -
430645 -
430646 -
430647 -
430648 -
430649 -
430650 -
430651 -
430652 -
430653 -
430654 -
430655 -
430656 -
430657 -
430658 -
4307 -