CONTACTS
SUBJECTS
VA EGD Procedure Dilate Stricture Lower Esophageal Sphincter Valve L
4403 -
4403 - ..
4404 - Summary/Objective
4405 -
440501 - Follow up ref SDS 86 0000. ref SDS 77 0000.
440502 -
440503 -
440504 -
440506 - ..
4406 -
4407 -
4408 - Background
4409 -
440901 - On 101210 EGD procedure dilated esophageal sphincter valve from 11 to
440902 - 14 mm. EGD today dilate from 14 to 17 mm. ref SDS 66 BF6L
440904 - ..
440905 - Test today was schedule in VA's letter dated 101210, received on
440906 - 101214 2330. ref SDS 68 ZG7O
440908 - ..
440909 - On 101216 1021 letter commends medical team for excellent work, and
440910 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
440912 - ..
440913 - On 110218 0730 4th EGD dilation at VA in Martinez, 110218 0730,
440914 - ref SDS 72 SR8M, and using anesthesia with Fentanyl. ref SDS 72 SR5O
440916 - ..
440917 - On 110429 0830 5th EGD dilation at VA in Martinez, 110429 1230,
440918 - ref SDS 77 NU8L, and using anesthesia with Fentanyl. ref SDS 77 SR5O
440919 - Good results dilating stricture in LESV to "ring finger," Next EDG
440920 - dilation ordered in 3 months, on 110729 0730. ref SDS 77 LJ6J
440922 - ..
440923 - On 110607 1414 visited GI Department, ref SDS 81 HC5H, and Charlene
440924 - reported a computer mistakes requires scheduling next EGD dilation on
440925 - 110819 0830. ref SDS 81 N642 Requested meeting with Doctor Lee, and
440926 - for the purpose of reviewing pending action items. ref SDS 81 4P6J,
440928 - ..
440929 - 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter
440930 - valve. ref SDS 86 K37G
440932 - ..
440933 - 111115 1300 EGD and Dilation structure lowere esphageal sphincter
440934 - valve (LESV), after 5 months. ref SDS 0 K37G
440935 -
440936 -
440938 - ..
4410 -
4411 -
4412 - Progress
441301 - ..
441302 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
441303 - GI Department VA Sacramento Medical Center Administration EGD Dilation
441304 -
441305 - Follow up ref SDS 86 NU8L, ref SDS 77 NU8L.
441306 -
441307 - Applied pre-proc requirements for NPO after mid-night from letter on
441308 - 101015 1547. ref SDS 54 6F8M
441310 - ..
441311 - Checked in to GI Department at 1247.
441313 - ..
441314 - Prepared patient history questionaire for the procedure.
441316 - ..
441317 - Submitted Kathy's cell phone for designated driver.
441320 -
441321 -
441322 -
4414 -
SUBJECTS
Default Null Subject Account for Blank Record
4503 -
4504 - 1123
450501 - ..
450502 - Medical Records Ordered for Case Management
450503 -
450504 - Follow up ref SDS 86 4U55, ref SDS 77 4U55.
450505 -
450506 - Forgot to order medical records after the procedure. Was a little
450507 - groggy from sedation.
450509 - ..
450510 - [On 120120 1425 received medical chart for work today.
450511 - ref SDS 90 RU5G
450512 -
450513 -
450514 -
450515 -
450517 - ..
4506 -
4507 -
4508 - 1218
4509 -
450901 - We went to lunch at the Buttercup on Clayton and Treat, and then came
450902 - home and began entering the record.
450903 -
450910 - ..
450911 - While at home entering the record for work today, Kathy recalled we
450912 - did not stop at ROI to see Wilma for ordering the medical chart on
450913 - work at the VA the past month.
450915 - ..
450916 - Called Wilma and asked if she might be able to prepare medical
450917 - records on a CD in time to leave town next Tuesday on 110823.
450919 - ..
450920 - Wilma said will try.
450922 - ..
450923 - Kathy drove us back to the VA.
450924 -
450926 - ..
4510 -
4511 -
4512 - 1348
4513 -
451301 - We went to Release of Information (ROI) Department on the 2nd floor
451302 - and met with Wilma. Filled out form requesting medical chart for...
451303 -
451304 - 1. Lab............................ 110727 1238, ref SDS 82 RP4N
451305 - 2. Meeting Doctor Sandhu.......... 110803 1400, ref SDS 83 PP8W
451306 - 3. Meeting Doctor Egan............ 110817 1030, ref SDS 84 JE5I
451307 - 4. Meeting Doctor Lee............. 110819 0830, ref SDS 86 SR8M
451308 -
451309 -
451310 -
451311 -
451312 -
4514 -
SUBJECTS
Default Null Subject Account for Blank Record
4603 -
4604 - 0852
460501 - ..
460502 - Signature Requested Blank Form on Understanding Discharge Instructions
460503 -
460504 - Follow up ref SDS 86 SR8M, ref SDS 77 SR8M.
460505 -
460506 - Iris called patient into pre-op, took vitals, and set a catheter to
460507 - inject anesthesthetic for conscious sedation, used later in the OR,
460508 - per below. ref SDS 86 SR5O
460510 - ..
460511 - Iris provided a document for signature...
460512 -
460513 - GI Discharge Instructions
460515 - ..
460516 - This document has no instructions, and no date nor time is entered.
460517 - Asked for clarification that the VA wants the patient to sign a blank
460518 - form?
460520 - ..
460521 - Iris confirmed explanation for prior procedure on 110429 1230.
460522 - ref SDS 77 IT7G
460524 - ..
460525 - [...below after the procedure, received in Recovery
460526 - Discharge form, signed in blank form before the procedure,
460527 - filled out in Recovery, ref SDS 77 ZI87; questions pending
460528 - on measurements from examination findings, ref SDS 77 538L,
460529 - and dose for Omeprazole medicaition. ref SDS 77 6Q4H
460530 -
460531 -
4606 -
SUBJECTS
Default Null Subject Account for Blank Record
4703 -
470401 - ..
470402 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
470403 -
470404 - Follow up ref SDS 86 UN6K, ref SDS 77 UN6K.
470405 -
470406 - Asked if Tunisia is working today, and can she do the IV, per
470407 - experience for prior procedure, when she was successful after others
470408 - had difficulty setting IV. 110429 1230, ref SDS 77 D95L
470410 - ..
470411 - Iris said that Tunisia is no longer working at the VA Martinez clinic.
470413 - ..
470414 - Iris was successful on 1st try getting blood flow for the IV needed
470415 - to provide sedation.
470417 - ..
470418 - This corrects prior problems reported in study on 110429 1230.
470419 - ref SDS 77 UN6K
470421 - ..
470422 - After getting documentation entered in computer, Iris facilitated
470423 - weigh in down the hall - weight 192.
470424 -
470425 - [On 110823 1158 weigh in 189 in Primary Care.
470426 - ref SDS 87 125O
470427 -
470428 -
470429 -
470430 -
4705 -
SUBJECTS
Default Null Subject Account for Blank Record
4803 -
4804 - 0913
480501 - ..
480502 - Consent Signed Continue Dilation Improve Swallowing
480503 -
480504 - Follow up ref SDS 86 SR4G, ref SDS 77 SR4G.
480506 - ..
480507 - Visited with Kendal before Doctor Lee arrived.
480509 - ..
480510 - Advised that have never had stomach pain often called "heart burn,"
480511 - and so asked how this aligns with getting treatment with Omeprazole?
480513 - ..
480514 - Kendal explained that patients can suffer stomach acid problems
480515 - without feeling discomfort or any symptoms. Evidence of stomach acid
480516 - in this case is evident from continuing stricture in LESV.
480518 - ..
480519 - Kendal also advised that average healthy LESV diameter is 20 mm, which
480520 - was presented previously on 110819 0830. ref SDS 86 N33J
480522 - ..
480523 - He recalled that the doctor dilated the LESV to 16.5 mm for the prior
480524 - procedure on 110429. 110819 0830, ref SDS 86 J978
480526 - ..
480527 - He seemed further to say that normally, the doctor does not dilate
480528 - to 20 mm. The reason was unclear during this discussion.
480529 -
480531 - ..
4806 -
4807 -
4808 - 0932
4809 -
480901 - Doctor Lee arrives. Shook hands. Signed consent for the procedure.
480903 - ..
480904 - Doctor Lee clarified that Omperazole should be taken twice a day
480905 - regardless of eating meals.
480907 - ..
480908 - Asked about report by Ray at the front desk, that Doctor Lee is
480909 - leaving the VA practice at the end of this month?
480911 - ..
480912 - Doctor Lee said he will continue seeing patients at VA Clinic in
480913 - Martinez until December, so we can do the next procedure here
480914 - scheduled for November, planned by Charlene on 110607 1414.
480915 - ref SDS 81 NG52
480917 - ..
480918 - After November, the doctor will only treat patients at the VA Medical
480919 - Center in Sacramento.
480921 - ..
480922 - The doctor left to continue work with other patients.
480923 -
480924 -
480925 -
480927 - ..
4810 -
4811 -
4812 - 1002
4813 -
481301 - Kendall walked patient into OR.
481302 -
481303 - In the OR, Kendall was assisted by Tom, who again remembered me from
481304 - prior work on 101210 0930. ref SDS 66 IR4J
481306 - ..
481307 - Tom applied Lidocaine to numb the throat, using an instrument with a
481308 - long tube to squirt the back of the throat, gargel and then swallow
481309 - the Lidocaine. This is done twice, once on each side of the throat,
481310 - and set out in the record for the last procedure on 110429 1230.
481311 - ref SDS 77 UO6L
481313 - ..
481314 - Kendal connected sedation injections into the IV, starting with
481315 - Fentynal.
481316 -
481317 -
481318 -
481319 -
481320 -
4814 -
SUBJECTS
Default Null Subject Account for Blank Record
4903 -
490401 - ..
490402 - Medical Chart Progress Notes
490403 - Chronic Swallowing Requires Dilation Conflicts Objectives Surgery
490404 -
490405 - Follow up ref SDS 86 XP8K, ref SDS 77 QF6L.
490406 -
490407 - F:\05\00003\SM\CC\AGMJ\20111115-130030\welch-112211.pdf
490409 - ..
490410 - LOCAL TITLE: EGD 60111
490411 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
490412 - DATE OF NOTE: NOV 15, 2011@13:00 ENTRY DATE: NOV 16, 2011@14:31:18
490413 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
490414 - URGENCY: STATUS: COMPLETED
490415 -
490416 - *** EGD 60111 Has ADDENDA ***
490418 - ..
490419 - PATIENT NAME: WELCH, RODNEY CHARLES
490420 - DATE OF BIRTH: 03/01/1945
490422 - ..
490423 - 1. PROCEDURE:
490424 -
490425 - 1. Esophagogastroduodenoscopy.
490426 - 2. Endoscopic biopsy.
490427 - 3. TTS balloon dilation of distal esophagus.
490429 - ..
490430 - 2. ATTENDING PHYSICIAN: Randall E. Lee, M.D.
490432 - ..
490433 - 3. INDICATIONS:
490434 -
490435 - 1. Rodney Welch is a 66-year-old man with a prior history of
490436 - achalasia. He underwent laparoscopic fundoplication and
490437 - myotomy. Subsequently, he developed an acid reflux distal
490438 - esophageal stricture that has required repeated endoscopic
490439 - dilation and more recently dilation plus injection of
490440 - triamcinolone. His most recent EGD was August 2011, at
490441 - which time his distal esophagus was dilated to 16.5 mm. He
490442 - received triamcinolone acetate injection into the site of
490443 - the stricture.
490445 - ..
490446 - 2. He is now here for reevaluation and possible further
490447 - dilation. He notes that his swelling has been maintained
490448 - relatively well with the exception of some accumulation of
490449 - saliva recently.
490451 - ..
490452 - 4. CONSENT:
490454 - ..
490455 - The risks, benefits, and alternatives to this procedure
490456 - including, but not limited to the risks of bleeding and bowel
490457 - perforation were explained to the patient. The patient
490458 - understood and provided written informed consent.
490460 - ..
490461 - 5. INTRAVENOUS MEDICATION:
490462 -
490463 - 1. Diphenhydramine 50 mg.
490464 - 2. Fentanyl 200 mcg.
490465 - 3. Midazolam 4 mg.
490466 -
490467 - [On 120322 1030 on next EGD dilation procedure, Fentanyl
490468 - was reduced from 200 mcg to 150 mcg. ref SDS 91 TN6J
490470 - ..
490471 - [On 120925 0900 Fentanyl was increased back to 200 mcg for
490472 - the next EGD dilation procedure. ref SDS 93 625J
490474 - ..
490475 - 6. PROCEDURE:
490476 -
490477 - 1. In the Martinez VA GI Endoscopy Unit the patient was placed
490478 - in the left lateral decubitus position.
490479 -
490480 - 2. Oxygen at 2 liters per minute by nasal cannula was
490481 - administered.
490483 - ..
490484 - 3. Continuous oxymetric and hemodynamic monitoring was
490485 - initiated.
490487 - ..
490488 - 4. Intravenous sedation was administered in divided doses.
490490 - ..
490491 - 5. After a bite block was placed in the patient's mouth, an
490492 - Olympus GIF-Q180 video gastroscope was advanced under
490493 - direct vision to the esophagus.
490495 - ..
490496 - 6. Some retained saliva in the esophagus was easily irrigated
490497 - and suctioned away.
490499 - ..
490500 - 7. At approximately 39 cm was a mild esophageal narrowing
490501 - without evidence of mass effect. The endoscope passed
490502 - easily through this narrowing and advanced into the
490503 - descending duodenum.
490505 - ..
490506 - 8. Retroflexed views of the incisura, fundus, and cardia were
490507 - performed.
490509 - ..
490510 - 9. Random biopsies were obtained from the esophagus at 35 cm
490511 - at the level of a previously tattooed site. No obvious
490512 - mucosal abnormalities were identified there. These were
490513 - labeled Specimen A.
490515 - ..
490516 - 10. A similar set of biopsies were obtained from the
490517 - gastroesophageal junction at approximately 40 cm and
490518 - labeled Specimen B.
490520 - ..
490521 - 11. A TTS balloon dilator was then advanced across the distal
490522 - esophagus inflated to 15 mm. The balloon did not engage
490523 - the stricture, and the balloon was then inflated to 16.5
490524 - mm. Again, the balloon did not engage the esophagus and so
490525 - the balloon was inflated to 18 mm. This engaged the
490526 - esophagus and a small mucosal tear was noted. No evidence
490527 - of perforation was identified.
490528 -
490529 - LESV Dilated
490530 - Date from - to
490531 - 111115 16.5 18...................... ref SDS 0 IR57
490532 - 110819 15 16.5...triamcinolone.... ref SDS 86 J978
490533 - 110429 13 16.5...triamcinolone.... ref SDS 77 U23I
490534 - 110218 11 14.....triamcinolone.... ref SDS 72 AA5O
490535 - 101210 11 14...................... ref SDS 66 H347
490536 - 100827 11 15...................... ref SDS 49 JE6X
490537 - 100305 11 15...................... ref SDS 42 WR6L
490539 - ..
490540 - [On 120322 1030, record of next EGD dilation indicates
490541 - LESV dilated from 16.5 mm to 18 mm. ref SDS 92 516N
490543 - ..
490544 - 12. Triamcinolone acetate was not injected at this time.
490546 - ..
490547 - Case study from VA Progress Notes indicates injecting triamcinolone
490548 - steriod has yielded favorable results, per above. ref SDS 0 IR57
490549 -
490550 - [...below on 111115 1300 not injecting triamcinolone
490551 - steriod into LESV to resist contraction, so that
490552 - swallowing is not impeded, and thus preventing
490553 - vomitting, appears conflicting with doctor's Impression
490554 - that triamcinolone steriod protocol has effective.
490555 - ref SDS 0 AW6J
490557 - ..
490558 - [On 120925 0900 Progress Notes report triamcinolone
490559 - steriod injections resumed to resist contraction of LESV
490560 - that aids swallowing. ref SDS 94 R87N
490562 - ..
490563 - 13. The stomach was decompressed and the gastroscope removed.
490565 - ..
490566 - 7. COMPLICATIONS: None.
490568 - ..
490569 - 8. FINDINGS:
490570 -
490571 - 1. Previous area of esophagus tattoo at approximately 34-35
490572 - cm, once again without evidence of mass effect. This area
490573 - was biopsied for any evidence of microscopic changes.
490574 -
490575 - 2. Esophageal stricture at approximately 39 cm without
490576 - evidence of mass effect. As measured by the balloon dilator
490577 - this has maintained its patency at approximately 16.5 mm
490578 - and was dilated to 18 mm today.
490580 - ..
490581 - 3. Atonic esophageal body with mildly friable mucosa and
490582 - retained saliva, but no food contents.
490584 - ..
490585 - 4. Distorted fundus consistent with known fundoplication.
490587 - ..
490588 - 5. Mild gastric mucosal erythema without evidence of mass,
490589 - ulcerations or erosions.
490591 - ..
490592 - 6. Normal pylorus.
490594 - ..
490595 - 7. Normal duodenum to D2.
490597 - ..
490598 - 9. IMPRESSION:
490599 -
490600 - 1. Gastroesophageal reflux stricture now obviously responding
490601 - to a combination of proton pump inhibitor therapy, dilation,
490602 - and prior triamcinolone acetate injection.
490604 - ..
490605 - The doctor's analysis of benefits injecting triamcinolone steriods
490606 - aligns with case study showing favorable response to treatment, above.
490607 - ref SDS 0 IR57
490609 - ..
490610 - Since the doctor concludes patient responding well to combination of
490611 - Omeprazole, dilation and triamcinolone injection into LESV to resist
490612 - contraction, so that normal swallowing is maintained to avoid
490613 - vomitting, not clear why triamcinolone injection was not done today,
490614 - as reported in Progress Notes above. ref SDS 0 IS6L
490616 - ..
490617 - Progress Notes for meeting on 111115 continue...
490618 -
490619 - 2. Atonic esophageal body with retained esophageal saliva
490620 - consistent with known diagnosis of achalasia.
490622 - ..
490623 - 10. RECOMMENDATIONS:
490624 -
490625 - 1. Continue omeprazole 40 mg twice daily 15-30 minutes before a
490626 - meal without reduction.
490628 - ..
490629 - 2. The patient is counseled to remain upright after eating for
490630 - approximately 30 minutes and to continue to wash solid food
490631 - down with liquids.
490633 - ..
490634 - 3. Repeat EGD with dilation in approximately 6 months on a
490635 - routine basis.
490637 - ..
490638 - 11. DISPOSITION:
490639 -
490640 - 1. The patient was observed in the Recovery Room then
490641 - discharged to home with a companion.
490642 -
490643 - 2. I reviewed the endoscopic findings with the patient and his
490644 - sister prior to discharge.
490646 - ..
490647 - 3. The patient requests that I perform his next endoscopy
490648 - whether I am assigned to Martinez or the Sacramento VA at
490649 - the appropriate time.
490651 - ..
490652 - 12. D: 11/15/2011
490653 - T: 11/16/2011
490654 - Job number: 898857
490655 - VJJ/CMTS
490656 - $end:
490657 -
490658 - /es/ RANDALL E LEE, MD
490659 - STAFF PHYSICIAN, GASTROENTEROLOGY
490660 - Signed: 11/18/2011 16:30
490661 -
490662 -
490663 - 13. 11/18/2011 ADDENDUM STATUS: COMPLETED
490664 -
490665 - Microscopic exam/diagnosis: (Date Spec taken: Nov 15, 2011)
490666 -
490667 - A. ESOPHAGUS AT 35CM (BIOPSY):
490668 -
490669 - - REFLUX ESOPHAGITIS MARKED ACUTE INFLAMMATION, SEE COMMENT
490670 - - NO EVIDENCE OF HELICOBACTER PYLORI IS SEEN WITH WARTHIN-STARRY STAIN
490672 - ..
490673 - B. GASTROESOPHAGEAL JUNCTION AT 40CM (BIOPSY):
490674 -
490675 - - REFLUX ESOPHAGITIS WITH OXYNTO-CARDIAC METAPLASIA
490676 - - NO INTESTINAL METAPLASIA (NO BARRETT'S ESOPHAGUS)
490678 - ..
490679 - COMMENTS:
490680 -
490681 - 1. A GMS stain is negative for fungal elements in part "A".
490682 -
490683 -
490685 - ..
490686 - Medical Chart Letter to Patient
490687 - Chronic Swallowing Requires Dilation Conflicts Objectives Surgery
490688 -
490689 -
490690 - 1. Martinez VA
490691 -
490692 - 2. Date.......................... 18 November 2011
490693 -
490703 - ..
490704 - 3. You had an examination of your esophagus, stomach, and duodenum
490705 - (EGD) at the Martinez VA OPC on 15 November 2011. I'm pleased
490706 - to report to you that the biopsies of your esophagus showed NO
490707 - cancer, precancerous conditions, or infection.
490709 - ..
490710 - 4. I'd like to repeat the EGD and dilation in about 6 months.
490711 - This will probably be at the Sacramento VAMC since I'm
490712 - transitioning out of Martinez.
490722 - STAFF PHYSICIAN, GASTROENTEROLOGY
490723 - Signed: 11/18/2011 17:09
490724 -
490725 -
490726 -
490727 -
490728 -
490729 -
490730 -
490731 -
490732 -
490733 -
490734 -
490735 -
490736 -
4908 -