CONTACTS
SUBJECTS
VA EGD Procedure Dilate Stricture Lower Esophageal Sphincter Valve L
5203 -
5203 - ..
5204 - Summary/Objective
5205 -
520501 - Follow up ref SDS 93 0000. ref SDS 90 0000.
520502 -
520503 -
520504 -
520505 -
520507 - ..
5206 -
5207 -
5208 - Background
5209 -
520901 - On 101210 EGD procedure dilated esophageal sphincter valve from 11 to
520902 - 14 mm. EGD today dilate from 14 to 17 mm. ref SDS 66 BF6L
520904 - ..
520905 - Test today was schedule in VA's letter dated 101210, received on
520906 - 101214 2330. ref SDS 68 ZG7O
520908 - ..
520909 - On 101216 1021 letter commends medical team for excellent work, and
520910 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
520912 - ..
520913 - On 110218 0730 4th EGD dilation at VA in Martinez, 110218 0730,
520914 - ref SDS 73 SR8M, and using anesthesia with Fentanyl. ref SDS 73 SR5O
520916 - ..
520917 - On 110429 0830 5th EGD dilation at VA in Martinez, 110429 1230,
520918 - ref SDS 78 NU8L, and using anesthesia with Fentanyl. ref SDS 78 SR5O
520919 - Good results dilating stricture in LESV to "ring finger," Next EDG
520920 - dilation ordered in 3 months, on 110729 0730. ref SDS 78 LJ6J
520922 - ..
520923 - On 110607 1414 visited GI Department, ref SDS 82 HC5H, and Charlene
520924 - reported a computer mistakes requires scheduling next EGD dilation on
520925 - 110819 0830. ref SDS 82 N642 Requested meeting with Doctor Lee, and
520926 - for the purpose of reviewing pending action items. ref SDS 82 4P6J,
520928 - ..
520929 - 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter
520930 - valve. ref SDS 87 K37G
520931 -
520932 - 111115 1300 EGD and Dilation structure lowere esphageal sphincter
520933 - valve (LESV), after 5 months. ref SDS 90 K37G
520934 -
520935 - 120322 1030 EGD and Dilation structure lowere esphageal sphincter
520936 - valve (LESV), after 5 months. ref SDS 93 K37G
520937 -
520938 - 120925 0900 meeting Doctor Lee reported schedule mistake using new VA
520939 - business unit; reported patient history. Scheduled EGD and dilation
520940 - procedure for 1300; returned and performed procedure; dilated from 9
520941 - mm to 18 mm.
520942 -
520943 -
520944 -
520945 -
520946 -
520948 - ..
5210 -
5211 -
5212 - Progress
521301 - ..
521302 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
521303 - GI Department VA Sacramento Medical Center Administration EGD Dilation
521304 -
521305 - Follow up ref SDS 93 NU8L, ref SDS 90 NU8L.
521306 -
521307 - Applied pre-proc requirements for NPO after midnight, from letter on
521308 - 101015 1547. ref SDS 54 4J9L Last liquid was on 120924 2217, and
521309 - last food was at 120924 1720.
521311 - ..
521312 - Stayed at Kathy's place last night in Sacremento. This morning, She
521313 - drove us to VA Medical Center at Mather AFB.
521315 - ..
521316 - Checked into GI Department at the customer counter.
521318 - ..
521319 - Submitted Kathy's cell phone for designated driver.
521323 - ..
521324 - Kathy signed the discharge form affirming she will be designated
521325 - driver, and responsible to facilitate no driving for 24 hours.
521327 - ..
521328 - Nurse at customer counter asked questions on patient history to verify
521329 - ready for procedure, e.g., no allergies, and NPO after midnight to
521330 - avoid conflicts with anesthesia; no health problems, e.g., no
521331 - diabetes, alcohol, cigarettes.
521333 - ..
521334 - Waited in lobby for 5 minutes.
521335 -
521337 - ..
5214 -
5215 -
5216 - 0913
5217 -
521701 - Meeting Review Pending Issues EGD Dilation Procedure
521702 - Consultation Review Pending Issues EGD Dilation Procedure
521703 -
521704 - Follow up ref SDS 93 SR4G, ref SDS 90 SR8M.
521706 - ..
521707 - Doctor Lee called us into an examination room.
521709 - ..
521710 - This procedure conflicts with past practice for pre-proc preperation
521711 - performed by medical staff.
521713 - ..
521714 - The doctor's new daughter adopted last year, when he and his wife
521715 - traveled to China in December 2011, is doing well. They greatly
521716 - enjoy having a 12 year old and their new baby.
521718 - ..
521719 - Doctor Lee advised that the VA made a mistake scheduling the meeting
521720 - today for examination only, and failed to schedule the EGD procedure,
521721 - contrary to his letter on 120330 1418. ref SDS 96 8492
521723 - ..
521724 - The doctor explained that work scheduling procedures, like EGD
521725 - Dilation, has been removed from the Gastrointestinal Clinic, and
521726 - assigned to a new centralized management business unit. This has
521727 - caused numerous scheduling mistakes with other patients, as occurred
521728 - today. The GI Clinic is assembling a case study to support filing a
521729 - proposal for saving time and money by reducing mistakes from restoring
521730 - scheduling work to the clinic.
521732 - ..
521733 - Doctor Lee said that since the patient has traveled from Concord, he
521734 - will arrange to perform planned EGD Dilation procedure later today at
521735 - 1300, and asked if that time would be convenient.
521737 - ..
521738 - This was agreed.
521740 - ..
521741 - The doctor left the meeting to coordinate adding another medical
521742 - procedure to the calendar for today at 1300.
521743 -
521745 - ..
5218 -
5219 -
5220 - 0926
5221 -
522101 - Comprehensive Health Care Improves Doctor Read Progress Notes
522102 - Doctor Read Progress Notes on Cardiology Prepare for EGD Procedure
522103 -
522104 - Doctor Lee returned and advised that the procedure is scheduled for
522105 - 1300 today.
522107 - ..
522108 - Doctor Lee reported having read the medical chart for meeting with
522109 - Doctor Egan in cardiology at the Martinez clinic earlier this month on
522110 - 120906 1100, ref SDS 97 NS8N
522111 -
522112 - [On 131115 0700 Doctor Lee made further progress advancing
522113 - doctor/patient partnership being prepared for effective
522114 - meetings by reading the record from prior meeting on
522115 - cardiology. This can be leveraged by electronic
522116 - communication with the customer that enables anytime,
522117 - anywhere intelligence on the Internet. ref SDS A5 ET4I
522119 - ..
522120 - The doctor was aware of side affects from Rosuvastatin and Omeprazole
522121 - reviewed with Doctor Egan on 120906 1100, ref SDS 97 I05F, and
522122 - presented in the medical chart.
522124 - ..
522125 - Explained that dehydration, caused by Rosuvastatin 20 mg caused severe
522126 - dry mouth and sore throat. This lasted over a month.
522128 - ..
522129 - Doctor Lee was further aware that in order to reduce adverse side
522130 - effects, Doctor Egan ordered reduced dose for Rosuvastatin 10 mg from
522131 - 20 mg, and also reduced Omeprazole 20 mg from 40 mg, further shown on
522132 - 120906 1100, ref SDS 97 M84M, and in the medical chart.
522134 - ..
522135 - We reviewed the record showing side effects have siginficantly
522136 - improved after reducing medications on 120906, and as shown in case
522137 - study on patient history on 101010 0744. ref SDS 52 4S7F and citing
522138 - the record for 120918. ref SDS 52 SJ5J
522139 -
522140 - 1. Peripheral neuropathy declined........... 90%
522141 - 2. Dizziness declined....................... 100%
522142 - 3. Sore throat declined..................... 100%
522144 - ..
522145 - Doctor Lee was very pleased with decline in side effects after
522146 - reducing medicaitons on 120906.
522148 - ..
522149 - Reported sore throat lasted for over a month, until Rosuvastatin 10
522150 - mg was reduced from 20 mg on 120906.
522152 - ..
522153 - Doctor Lee explained that he will check for residual effects from
522154 - prolonged soar throat during EGD examination today.
522156 - ..
522157 - Vitals have improved with blood pressure and heart rate dropping after
522158 - reducing Omeprazole, reported in patient history on 120908 shown in
522159 - case study on 101010 0744. ref SDS 52 WR5G
522160 -
522161 -
5222 -
SUBJECTS
Default Null Subject Account for Blank Record
5303 -
530401 - ..
530402 - Dilate 20 mm LESV Improve Swallowing Reduce Vomitting
530403 -
530404 - Discussed entering in the medical chart metrics to evaluate
530405 - effectiveness of pneumatic dilation. Doctor Lee will enter in the
530406 - medical chart today starting and ending dilation values, e.g., initial
530407 - LESV 16 mm and dialted to 20 mm.
530409 - ..
530410 - Discussed dilating to 20 mm today, based on Kendahl's report that
530411 - healthy LESV typically dialates to 20 mm during swallowing, shown on
530412 - 110819 0830. ref SDS 87 N33J Kendahl mentioned this criteria again
530413 - during the next meeting on 111115 1300. ref SDS 90 N33J
530414 -
530415 - [...below on 120925 0900 LESV dilated to 18 mm during
530416 - procedure, rather than size of healthy LESV 20 mm.
530417 - ref SDS 0 XB51
530418 -
530419 -
530420 -
5305 -
SUBJECTS
Default Null Subject Account for Blank Record
5403 -
540401 - ..
540402 - Swallowing Difficulties Increased Vomitting
540403 - Triamcinoloe Steriod Injection Resumed Prevent LESV Contraction
540404 -
540405 - Follow up ref SDS 93 UI9H.
540406 -
540407 - Doctor Lee asked about swallowing and vomitting?
540409 - ..
540410 - Reported swallowing generally good, and so vomitting mostly mild
540411 - during past 6 months, since prior procedure on 120322 1030,
540412 - ref SDS 93 K37G Swallowing and vomitting problems have increased the
540413 - past few months, similar to pattern following EGD dilation procedure
540414 - on 120322, ref SDS 93 UI9H, when triamcinolone steriod injection was
540415 - not performed on 111115, as reported in VA Progress Notes. ref SDS 90
540416 - IS6L Immediately after dilation on 111115, there were no problems for
540417 - weeks; but, occasionally severe vomitting. Case study on 120101,
540418 - shows increased vomitting past 2 months, and beginning on 120331
540419 - 120101 0900, ref SDS 92 QWPY...
540420 -
540421 - 10%.................... 120331
540422 - 20%.................... 120523
540423 - 80%.................... 120613
540424 - 2%.................... 120627
540425 - 100%.................... 120714
540426 - 20%.................... 120801
540427 - 40%.................... 120803
540428 - 40%.................... 120804
540429 - 40%.................... 120805
540430 - 20%.................... 120818
540431 - 80%.................... 120819
540432 - 2%.................... 120901
540433 - 2%.................... 120902
540434 - 30%.................... 120911
540435 - 30%.................... 120916
540436 - 20%.................... 120921
540438 - ..
540439 - Doctor Lee indicated the past 2 procedures on 111115, and on 120322,
540440 - experimented to assess contraction of LESV following dilation, and
540441 - consequent effect on swallowing and vomitting that occurs without
540442 - injecting triamcinolone steriod into LESV.
540444 - ..
540445 - The doctor indicated severe swallowing and vomitting problems will be
540446 - reduced this cycle by adding triamcinolone injection today that
540447 - resists contraction of LESV, as explained previously on 110218 0730.
540448 - ref SDS 73 SR4G Doctor Lee recalled that adding triamcinolone
540449 - injections to compliment Omeprazole medication and dilation of LESV
540450 - was effective last year, presented previously in the doctor's Progress
540451 - Notes on 111115, saying...
540453 - ..
540454 - Gastroesophageal reflux stricture now obviously responding
540455 - to a combination of proton pump inhibitor therapy,
540456 - dilation, and prior triamcinolone acetate injection.
540457 - ref SDS 90 AW6J
540458 -
540459 - LESV Dilated
540460 - Date from - to
540461 - 120925 15 18.....triamcinolone.... ref SDS 0 XB51
540462 - 120322 16.5 18...................... ref SDS 93 516N
540463 - 111115 16.5 18...................... ref SDS 90 IR57
540464 - 110819 15 16.5...triamcinolone.... ref SDS 87 J978
540465 - 110429 13 16.5...triamcinolone.... ref SDS 78 U23I
540466 - 110218 11 14.....triamcinolone.... ref SDS 73 AA5O
540467 - 101210 11 14...................... ref SDS 66 H347
540468 - 100827 11 15...................... ref SDS 49 JE6X
540469 - 100305 11 15...................... ref SDS 42 WR6L
540471 - ..
540472 - [...below on 120925 0900 Progress Notes report triamcinolone
540473 - steriod injection resumed in order to relieve swallowing
540474 - problems. ref SDS 0 R87N
540476 - ..
540477 - [...below on 120925 0900 doctor concludes today in Impression
540478 - section of Progress Notes that Gastroesophageal reflux
540479 - stricture with significant recurrence from prior examination
540480 - and dilation of March 2012. This progression of stricture may
540481 - have resulted from nonuse of triamcinolone acetate on the
540482 - prior endoscopic therapies. ref SDS 0 E558
540484 - ..
540485 - [On 130110 0900 Progress Notes report Doctor Lee continued
540486 - adding triamcinolone injection today, to resist contraction of
540487 - LESV that aids swallowing to avoid vomitting, ref SDS A1 Q34P,
540488 - evidenced by case study showing significantly reduced
540489 - vomitting during prior cycle after resuming triamcinolone
540490 - injections, ref SDS A1 SE7K; and aligns with prior practice on
540491 - 110429, continuing injections when experience showed
540492 - triamcinolone steriod injection was effective. ref SDS 78 SS5N
540493 - Continued response to treatment supported continuing
540494 - triamcinolone injection protocol for the next cycle on 110819.
540495 - ref SDS 87 J985
540497 - ..
540498 - [On 130416 1100 swallowing vomitting problems declined 75%
540499 - after resuming triamcinolone steriod injections to resist
540500 - contraction of LESV. ref SDS A4 SZ8M,
540501 -
540502 -
540503 -
540504 -
540505 -
540506 -
540507 -
540508 -
5406 -
SUBJECTS
Default Null Subject Account for Blank Record
5503 -
550401 - ..
550402 - Reflux Laying Left Side Due to Heller Myotomy Flap
550403 - Referral Doctor Stewart Reflux Problem Heller Myotopy Surgery Flap
550404 -
550405 - Reported new problem over the past 3 or 4 months. Severe reflux
550406 - occurs laying on left side. This does not occur laying on the back or
550407 - right side. Severe reflux causes significant choking, drowning, and
550408 - suffocating effect.
550409 -
550410 - [On 121016 1302 meeting with Doctor Stewart at VA San
550411 - Francisco Medical Center indicates backflow through wrap
550412 - should occur laying on right side, and not on the left
550413 - side. ref SDS 99 6O5I
550415 - ..
550416 - [On 121113 1100 Doctor Stewart explains that the "wrap"
550417 - which she constructed during Heller Myotomy surgery on
550418 - 091216, causes backflow (reflux) to occur laying on the
550419 - left side, rather normally on the right side. ref SDS A0
550420 - WB54
550422 - ..
550423 - Doctor Lee drew a diagram of the throat and stomach, similar to the
550424 - diagram Doctor Stewart submitted during the meeting to plan Heller
550425 - Myotomy surgery to resolve acalasia, reported on 091030 0810.
550426 - ref SDS 19 GM5I
550427 -
550428 -
550429 - | |
550430 - | | Throat
550431 - | |
550432 - | |
550433 - |||||||| Lower esophageal sphincter (LES) valve
550434 - ||||||||
550435 - / \
550436 - / -----\
550437 - | -\
550438 - | - Stomache
550439 - | |
550440 - / /
550441 - / --------- /
550442 - | /
550443 - \ \
550444 - \ -----------
550445 - ------------------
550447 - ..
550448 - Today, Doctor Lee rotated the diagram 90 degrees to explain that
550449 - laying on the left side causes stomach contents to flow back into the
550450 - Lower Esophageal Sphincter Valve (LESV). This does not occur laying
550451 - the back and right side. As a result, Heller Myotomy Surgery on
550452 - 091216, 091216 0600, ref SDS 31 KE9U, enables backflow into the throat
550453 - with access to breathing channels. This causes chocking and drowning
550454 - problems.
550456 - ..
550457 - Further review shows Doctor Stewart planned to construct a "flap" as
550458 - part of Heller Myotomy surgery on 091216, that would prevent backflow
550459 - from the stomach into the esophagus, further reported in the meeting
550460 - at the VA on 091030 0810. ref SDS 19 OY64
550462 - ..
550463 - Since the flap seems to be failing, Doctor Stewart may be able to
550464 - perform a surgical repair, or other remedy to accomplish original
550465 - objectives, including resolve achalasia so that swallowing can be
550466 - accomplished without continuing EGD dilation procedures, as planned in
550467 - the meeting on 091030 0810. ref SDS 19 P69G
550469 - ..
550470 - Doctor Lee will make a referral for surgery follow up with Doctor
550471 - Stewart.
550472 -
550473 - [...below on 120925 0900 addendum to Progress Notes on
550474 - 120928 reports referral to Doctor Stewart filed.
550475 - ref SDS 0 MY9M
550477 - ..
550478 - [On 121016 1302 Doctor Stewart at VA San Francisco Medical
550479 - Center orders barrium test to evaluate potential for
550480 - another surgery to improve swallowing without backflow
550481 - problems. ref SDS 99 FN4G
550482 -
550483 -
550484 -
5505 -
SUBJECTS
Default Null Subject Account for Blank Record
5603 -
560401 - ..
560402 - Accurate Record Improve Health Care Communication Assistant
560403 - Communication Assistant Accurate Record Improve Health Care
560404 - Health Care Improve Communication Assistant Accurate Record
560405 -
560406 - We reviewed the opportunity to help the medical team capture an
560407 - accurate, comprehensive record using another assistant for the
560408 - procedure today. Kathy is a 30 year nursing professional for
560409 - maternity practice with Sutter Medical Center in Sacramento. She
560410 - regularly assists with related surgical procedures. We want to
560411 - evaluate utility of cell phones now with expanded functionality for
560412 - capturing a greater share of organizational memory using a text entery
560413 - feature of the recently released Samsung Galaxy S III. While verbatim
560414 - transcript is not practical with cell phones, it may be possible to
560415 - enter key words and phrases in real time that aids preparation of
560416 - patient history for saving lives, time, and money.
560418 - ..
560419 - Doctor Lee explained VA resistance against observers in the OR during
560420 - medical procedures. He is concerned today about crowding in the OR.
560422 - ..
560423 - Decided to defer this initiative for further consideration in the next
560424 - procedure in 6 months.
560426 - ..
560427 - Reviewed with Doctor Lee problems getting completed and signed
560428 - Discharge document for the meeting on 120322, reported the next day on
560429 - 120323 0748. ref SDS 94 K37G This conflicts with prior practice when
560430 - the doctor entered post-procedure instructions, for example on 110429
560431 - 1230. ref SDS 78 DU6J
560433 - ..
560434 - This can be resolved by the patient signing the document after the
560435 - procedure and consultation with the doctor after recovery, and at the
560436 - time of discharge instead of before medical services are provided, as
560437 - commonly requested by VA staff, reported on 120322 1030. ref SDS 93
560438 - SR8M and ref SDS 93 PR4S
560440 - ..
560441 - The doctor said to return at 1230 for the procedure at 1300.
560442 -
560443 -
560444 -
5605 -
SUBJECTS
Default Null Subject Account for Blank Record
5703 -
5704 - 1230
570501 - ..
570502 - EGD Check In and Administration
570503 -
570504 - Follow up ref SDS 93 K37G.
570505 -
570506 - Checked into GI Department again at the customer counter.
570508 - ..
570509 - VA agent verified Kathy's cell phone for designated driver.
570510 -
570512 - ..
5706 -
5707 -
5708 - 1240
5709 -
570901 - Another nurse called the patient into a meeting.
570903 - ..
570904 - Kathy joined this meeting in a small office adjacent to the check-in
570905 - counter, as for prior procedure on 120322 1030. ref SDS 93 4E6O
570907 - ..
570908 - The nurse took vitals...
570909 -
570910 - Weight.................. 193
570911 - BP...................... 118 74
570912 - HR (pulse).............. 59
570913 - Temp.................... 97.6
570915 - ..
570916 - Initial blood pressure was reported erroneously very high, about 132
570917 - 78, as occurred previously on 120322 1030. ref SDS 93 4882 Since this
570918 - conflicts with patient history the past week, beginning on 120920, and
570919 - reported in case study on 101010 0744, ref SDS 52 MZ6I, blood pressure
570920 - was taken again and aligned with patient hisotry.
570922 - ..
570923 - Nurse asked further background on patient history, repeating and
570924 - extending questions presented during check-in, per above. ref SDS 0
570925 - ML8O
570926 -
570927 -
570928 -
5710 -
SUBJECTS
Default Null Subject Account for Blank Record
5803 -
5804 - 1244
580501 - ..
580502 - Signature Requested Blank Form on Understanding Discharge Instructions
580503 -
580504 - Follow up ref SDS 93 SR8M, ref SDS 90 SR8M.
580506 - ..
580507 - After completing vitals and another review of patient history, per
580508 - above, ref SDS 0 487K, Nurse requested signature and date on a form...
580509 -
580510 - GI Discharge Instructions
580512 - ..
580513 - This is the form Kathy signed earlier and entered her cell phone
580514 - number to identify the designated driver, per above. ref SDS 0 J355
580516 - ..
580517 - The form showed the patient's name and address at the bottom, and had
580518 - no instructions since medical services have not yet been performed.
580520 - ..
580521 - Explained will sign the Discharge Form after EGD Dilaiton procedures
580522 - are performed and results and instructions have been entered,
580523 - discussed with Doctor Lee this morning, shown above. ref SDS 0 737M
580525 - ..
580526 - The nurse explained VA procedure for patient to sign blank forms
580527 - acknowledging receipt of instructions which are not actually entered
580528 - on the document. The nurse said that after medical care is provided
580529 - today, the patient will get a copy of this pre-signed "Discharge
580530 - Instructions" form with instructions by the doctor on medications, and
580531 - findings from medical procedures. This aligns with prior VA guidance
580532 - on 110429 1230. ref SDS 78 IT7G
580534 - ..
580535 - We reviewed challenges busy providers face when rushed, shown in this
580536 - case and reviewed with the doctor, per above. ref SDS 0 737M
580538 - ..
580539 - Decided not to sign Discharge Documents until after information and
580540 - instructions are entered following completion of medical services
580541 - today.
580542 -
580543 - [...below on 120925 0900 at 1532 received and signed
580544 - completed Discharge form with signature and date.
580545 - ref SDS 0 PR4S
580547 - ..
580548 - The nurse fastened patient ID plastic bracelet on left arm.
580550 - ..
580551 - Went back to the lobby. There was another wait for about 5 minutes.
580552 -
580553 -
580554 -
580555 -
580556 -
5806 -
SUBJECTS
Default Null Subject Account for Blank Record
5903 -
5904 - 1255
590501 - ..
590502 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
590503 -
590504 - Follow up ref SDS 93 UN6K, ref SDS 90 UN6K.
590506 - ..
590507 - Nurse, called patient for pre-op.
590509 - ..
590510 - Went through a locked door into OR area. Nurse gave instructions to
590511 - dress down in a restroom.
590513 - ..
590514 - Layed on the gurney.
590516 - ..
590517 - Nurse asked more questions similar to those already answered, when the
590518 - Discharge document was signed 10 minutes earlier, per above.
590519 - ref SDS 0 UH7M The nurse entered responses into the computer again.
590521 - ..
590522 - Nurse was successful on 1st try getting blood flow for the IV needed
590523 - to provide sedation. This aligns with Lee's success on 1st attempt
590524 - setting IV during prior procedure on 120322 1030, ref SDS 93 4Z9O, and
590525 - previously Iris's success setting an IV on the first try for procedure
590526 - on 111115 1300, ref SDS 90 4Z9O, and further corrects prior problems
590527 - reported in study on 110429 1230. ref SDS 78 UN6K
590528 -
590529 -
590531 - ..
590532 - Meeting with Doctor Lee Sign Consent
590533 - Consent Signed Meeting with Doctor Lee
590534 -
590535 - Follow up ref SDS 93 SR4G, ref SDS 90 SR4G.
590536 -
590537 - Doctor Lee arrived.
590539 - ..
590540 - Since we reviewed pending issues earlier this morning, reported above,
590541 - ref SDS 0 RG9K, we only needed to do the sign consent procedure.
590543 - ..
590544 - Doctor Lee held an electronic instrument connected via cable to VA
590545 - computer system for entering a handwritten signature consenting to the
590546 - medical procedure. Nothing was explained and no language was
590547 - presented on content of consent, as done previously.
590549 - ..
590550 - Nothing was readable about consent to be signed.
590551 -
590552 -
590553 -
590554 -
590555 -
5906 -
SUBJECTS
Default Null Subject Account for Blank Record
6003 -
6004 - 1323
600501 - ..
600502 - OR EGD Dilation after 2nd Application Lidocaine
600503 - EGD Dilation Procedure in OR 2nd Application Lidocaine
600504 -
600505 - Follow up ref SDS 93 R94I, ref SDS 90 LE59.
600506 -
600507 - Was wheeled from pre-op into the OR.
600509 - ..
600510 - While still on the hospital bed, the procedure nurse came into the
600511 - Pre-op area. Asked the patient to sit up on the bed and squirted
600512 - Lidocaine to numb the throat, using an instrument that squirted agent
600513 - into the mouth, as explained in the record for the prior procedure on
600514 - 111115 1300. ref SDS 90 UO6L
600516 - ..
600517 - In the OR, there was a second application of Lidocaine to numb the
600518 - throat, as done previously, and citing the record for the earlier
600519 - procedure on 110429 1230. ref SDS 78 UO6L
600521 - ..
600522 - Then received Fentanyl and other drugs for conscious sedation, used
600523 - for anesthetic, reported in medical chart for procedure on 100827
600524 - 0738. ref SDS 49 JE9V
600526 - ..
600527 - For remainder of record see VA medical chart ordered after the
600528 - procedure, shown below. ref SDS 0 QF6L
600529 -
600530 -
600532 - ..
6006 -
6007 -
6008 - 1513
6009 -
600901 - Dilated 18 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee
600902 - Meeting Doctor Lee Present Results EGD Dilation Procedure
600903 - Results EGD Dilation Procedure Meeting Doctor Lee Present
600904 -
600905 - Follow up ref SDS 93 SR6K.
600906 -
600907 - Awake in recovery.
600909 - ..
600910 - Met Doctor Lee in the Recovery Room. Patient still groggy from
600911 - anesthesia. Could not conduct comprehensive meeting, and so did not
600912 - discuss findings from the procedure, as done for prior procedures,
600913 - e.g., on 110819 0830. ref SDS 87 SS5N
600915 - ..
600916 - Think he said dilation was only 18 mm, rather than work plan 20 mm,
600917 - per above. ref SDS 0 3D7K
600918 -
600919 - [...below on 120925 0900 LESV dilated to 18 mm during
600920 - procedure, rather than size of healthy LESV 20 mm.
600921 - ref SDS 0 XB51
600923 - ..
600924 - Rely on Progress Notes showing LESV dilated from initial 15 mm to 18
600925 - mm, ref SDS 0 XB51, and triamcinolone steriod injection was resumed,
600926 - ref SDS 0 R87N, after pausing the past 2 cycles, to recover from
600927 - swallowing and vomitting problems. ref SDS 0 E558
600928 -
600929 -
600930 -
600931 -
600932 -
6010 -
SUBJECTS
Default Null Subject Account for Blank Record
6103 -
6104 - 1513
610501 - ..
610502 - GI Discharge Instructions Another Blank Form
610503 -
610504 - Follow up ref SDS 93 PR4S, ref SDS 90 PR4S.
610505 -
610506 - Received documentation from the nurse, discussed earlier today, per
610507 - above. ref SDS 0 SR8M
610509 - ..
610510 - The form had some handwritten entries, so signed the document, as
610511 - planned in the meeting earlier this morning, shown above. ref SDS 0
610512 - AT9F
610513 -
610514 -
610515 -
610516 -
610517 -
6106 -
SUBJECTS
Default Null Subject Account for Blank Record
6203 -
620401 - ..
620402 - Medical Chart Progress Notes
620403 - Chronic Swallowing Requires Dilation Conflicts Objectives Surgery
620404 -
620405 - Follow up ref SDS 90 QF6L, ref SDS 86 QF6L.
620407 - ..
620408 - VA medical chart in pdf format is stored on...
620409 -
620410 - F:\05\00003\SM\CC\AGMJ\20120925-130002\welch_100412.pdf
620411 -
620412 - 1. LOCAL TITLE: EGD 60111
620413 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
620414 - DATE OF NOTE: SEP 25, 2012@13:00 ENTRY DATE: SEP 26, 2012@15:13:02
620415 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
620416 - URGENCY: STATUS: COMPLETED
620417 -
620418 - *** EGD 60111 Has ADDENDA ***
620420 - ..
620421 - PATIENT NAME: WELCH, RODNEY CHARLES
620422 - DATE OF BIRTH: 03/01/1945
620424 - ..
620425 - 1. NAME OF PROCEDURES:
620426 -
620427 - 1. Esophagogastroduodenoscopy.
620428 - 2. Through the scope balloon dilation of distal esophagus.
620429 - 3. Endoscopic biopsy.
620430 - 4. Endoscopic injectio of triamcinolone.
620432 - ..
620433 - 2. ATTENDING PHYSICIAN:
620434 -
620435 - Randall E. Lee, M.D.
620437 - ..
620438 - 3. INDICATIONS:
620441 -
620442 - 1. 67-year-old man with a history of known history of
620443 - achalasia. He underwent laparoscopic myotomy and
620444 - fundoplication at San Francisco VA Medical Center. He
620445 - subsequently developed acid reflux and a distal
620446 - esophageal stricture that required repeated endoscopic
620447 - dilation.
620449 - ..
620450 - 2. Previous dilations were associated with injection of
620451 - triamcinolone, although his most recent 2 examinations
620452 - and dilations were not associated with triamcinolone
620453 - injection.
620455 - ..
620456 - This aligns with the record on 120322 1030. ref SDS 93 5179
620458 - ..
620459 - Progress Notes procedure on 120925 continues...
620460 -
620461 - 3. His last EGD and dilation was March 2012, at which time
620462 - a balloon dilator was engaged with a stricture at 18
620463 - mm.
620465 - ..
620466 - 4. Triamcinolone was not injected at that time.
620468 - ..
620469 - This aligns with the record on 120322 1030. ref SDS 93 5179
620471 - ..
620472 - Progress Notes procedure on 120925 continues...
620473 -
620474 - 5. The patient is now here for reevaluation. In the
620475 - interim, he has noted a recent recurrence of some solid
620476 - food dysphagia. He continues to use proton pump
620477 - inhibitor therapy on a daily basis.
620479 - ..
620480 - "Proton pump inhibitor therapy" refers to Omeprazole pills.
620482 - ..
620483 - Dysphagia describes swallowing and vomitting problems, presented
620484 - during the meeting prior to the procedure earlier this morning, shown
620485 - above. ref SDS 0 TZ4M This also presented during the prior meeting on
620486 - 120322 1030. ref SDS 93 UI9H
620488 - ..
620489 - Progress accurately report patient taking prescribed dose of
620490 - Omeprazole, shown in case study patient history on 120101 0900.
620491 - ref SDS 92 QUWV Progress Notes today update prior record for
620492 - procedure on 120322 1030. ref SDS 93 AW6J
620494 - ..
620495 - Progress Notes procedure on 120925 continues...
620496 -
620497 - 4. CONSENT:
620499 - ..
620500 - 5. The risks, benefits, and alternatives to this procedure
620501 - including, but not limited to, the risks of bleeding and
620502 - bowel perforation, were explained to the patient. The
620503 - patient understood and provided written informed consent.
620505 - ..
620506 - 6. INTRAVENOUS MEDICATIONS:
620507 -
620508 - 1. Diphenhydramine 50 mg.
620509 - 2. Fentanyl 200 mcg.
620510 - 3. Midazolam 5 mg.
620512 - ..
620513 - 7. PROCEDURE:
620514 -
620515 - 1. In the Sacramento VA GI Endoscopy Unit, the patient was
620516 - placed in the left lateral decubitus position.
620517 -
620518 - 2. Oxygen at 2 liters per minute by nasal cannula was
620519 - administered. Continuous oximetric and hemodynamic
620520 - monitoring was initiated.
620522 - ..
620523 - 3. Intravenous sedation was administered in divided doses.
620525 - ..
620526 - 4. After a bite block was placed in the patient's mouth,
620527 - an Olympus GIFH180 videogastroscope was advanced under
620528 - direct vision into the esophagus.
620530 - ..
620531 - 5. Some retained saliva and food material within the
620532 - esophagus was easily irrigated and suctioned away.
620534 - ..
620535 - 6. At approximately 39-40 cm was an esophageal stricture,
620536 - which impeded the passage of the diagnostic endoscope,
620537 - but yielded to gentle pressure.
620539 - ..
620540 - 7. The endoscope was then advanced into the descending
620541 - duodenum. Retroflexed views of incisura, fundus, and
620542 - cardia were performed.
620544 - ..
620545 - 8. A TTS balloon dilator was advanced across the distal
620546 - esophagus and inflate to 15 mm. The balloon engaged
620547 - the esophagus at this size and the balloon was then
620548 - inflated to 16.5 and 18 mm subsequently.
620550 - ..
620551 - Dilating to 18 mm aligns with prior procedure on, 111115 1300,
620552 - ref SDS 90 IR57, rather than 20 mm to restore healthy LESV, discussed
620553 - during meeting earlier this morning, per above. ref SDS 0 3D7K
620554 -
620555 - LESV Dilated
620556 - Date from - to
620557 - 120925 15 18.....triamcinolone..4.0mL... ref SDS 0 XB51
620558 - 120322 16.5 18............................ ref SDS 93 516N
620559 - 111115 16.5 18............................ ref SDS 90 IR57
620560 - 110819 15 16.5...triamcinolone..2.5mL... ref SDS 87 J978
620561 - 110429 13 16.5...triamcinolone..3.5mL... ref SDS 78 U23I
620562 - 110218 11 14.....triamcinolone..2.0mL... ref SDS 73 AA5O
620563 - 101210 11 14............................ ref SDS 66 H347
620564 - 100827 11 15............................ ref SDS 49 JE6X
620565 - 100305 11 15............................ ref SDS 42 WR6L
620567 - ..
620568 - [On 130110 0900, LESV dilated again from 15 to 18 mm,
620569 - rather than size of healthy LESV 20 mm. ref SDS A2 Q333
620571 - ..
620572 - Progress Notes procedure on 120925 continues...
620573 -
620574 - 9. The balloon was then deflated, removed, and random
620575 - biopsies were taken from the following locations: GE
620576 - junction at 40 cm labeled A, 38 cm B, 36 cm C, 34 cm D,
620577 - 32 cm D, 30 cm F, and esophagus at 28 cm labeled G.
620579 - ..
620580 - 10. Subsequently, 4 mL of triamcinolone acetate as a
620581 - concentration of 40 mg/mL were injected into the distal
620582 - esophageal stricture between 40 and 39 cm. 1 mL into
620583 - each of 4 quadrants.
620585 - ..
620586 - This record is the first report that separate injections were made
620587 - into each of 3 quadrants.
620588 -
620589 - [On 141107 0800 Triamcinolone 4mL injected into LESV; there
620590 - is no explanation of separate 1mL injections into each of 3
620591 - quadrants. ref SDS A7 P38L
620593 - ..
620594 - Injecting triamcinolone steriod into LESV aligns with work plan to
620595 - resist contraction of LESV in order to aid swallowing and reduce
620596 - vomitting problems, discussed during the meeting earlier today, shown
620597 - above. ref SDS 0 TZ4M
620599 - ..
620600 - This reverses pausing injections for past 2 treatments on 111115 1300,
620601 - ref SDS 90 IS6L, and again on 120322 1030. ref SDS 93 5179
620602 -
620603 - [On 130416 1100 swallowing vomitting problems declined 75%
620604 - after resuming triamcinolone steriod injections to resist
620605 - contraction of LESV. ref SDS A4 SZ8M,
620607 - ..
620608 - [On 130416 1100 triamcinolone steriod injection again to
620609 - LESV. ref SDS A3 I167
620611 - ..
620612 - Progress Notes procedure on 120925 continues...
620613 -
620614 - 11. The stomach was decompressed and the gastroscope
620615 - removed. Complications none.
620617 - ..
620618 - 8. FINDINGS:
620619 -
620620 - 1. Previous area of esophageal tattoo between 34 and 35 cm
620621 - again noted, but once again without evidence of mass
620622 - effect.
620624 - ..
620625 - 2. Esophageal stricture between 39 and 40 cm, which at
620626 - initial estimation is approximately 9 mm in overall
620627 - diameter.
620629 - ..
620630 - 3. Atonic esophageal body with retained material, but
620631 - without friable mucosa. White adherent deposits
620632 - scattered throughout the esophageal body.
620634 - ..
620635 - 4. Distorted fundus consistent with known fundoplication.
620637 - ..
620638 - 5. Atrophic appearing distal antral gastric mucosa without
620639 - evidence of mass effect, ulcerations or erosions.
620641 - ..
620642 - 6. Normal pylorus.
620644 - ..
620645 - 7. Normal duodenum to D2.
620647 - ..
620648 - 9. IMPRESSION:
620649 -
620650 - 1. Gastroesophageal reflux stricture with significant
620651 - recurrence from prior examination and dilation of March
620652 - 2012. This progression of stricture may have resulted
620653 - from nonuse of triamcinolone acetate on the prior
620654 - endoscopic therapies.
620656 - ..
620657 - Attributing today, cause of continuing difficulty swallowing
620658 - (dysphagia), reported in case study earlier today, shown above,
620659 - ref SDS 0 TZ4M, to not injecting triancinolone steriod for the prior 2
620660 - cycles on 120322 1030, ref SDS 93 5179, and on 111115 1300,
620661 - ref SDS 90 IS6L, aligns with Progress Notes Impression that injecting
620662 - triamcinolone steriod beginning last year on 110218 0730, ref SDS 73
620663 - A296, resisted contraction of LESV which aided swallowing and reduced
620664 - vomitting, reported 9 months later on 111115 1300. ref SDS 90 AW6J
620666 - ..
620667 - This updates prior Impression that swallowing difficulties from
620668 - progression of LESV contraction were caused by self-reduction of
620669 - Omeprazole, entered in Progess Notes on 120322 1030. ref SDS 93 AW6J
620671 - ..
620672 - Progress Notes procedure on 120925 continues...
620673 -
620674 - 2. Atonic esophageal body consistent with known diagnosis
620675 - of achalasia.
620677 - ..
620678 - 3. Probable esophageal candidiasis.
620680 - ..
620681 - 4. Appearance of fundoplication, appears to be relaxed.
620683 - ..
620684 - 10. RECOMMENDATIONS:
620685 -
620686 - 1. Continue omeprazole 20 mg twice daily.
620687 - 2. Repeat EGD and dilation in approximately 6 months.
620688 - 3. Await the pathology results.
620689 -
620691 - ..
620692 - 11. TIME START: 1357 hours.
620693 - TIME END: 1432 hours.
620695 - ..
620696 - 12. DISPOSITION:
620697 -
620698 - 1. The patient was observed in the Recovery Room and then
620699 - discharged home with a companion.
620700 -
620701 - 2. I reviewed the endoscopic findings with the patient and
620702 - his sister-in-law prior to discharge.
620704 - ..
620705 - 13. D: 09/25/2012
620706 - T: 09/25/2012
620707 - Job number: 1028007
620708 - JLO/CMTS
620709 - $end:
620710 - /es/ RANDALL E LEE, MD
620711 - STAFF PHYSICIAN, GASTROENTEROLOGY
620712 - Signed: 09/28/2012 17:20
620713 -
620714 -
620715 - 2. 09/25/2012 ADDENDUM STATUS: COMPLETED
620716 - fu egd 1028007: dilated 15-18mm. injected triamcinolone
620718 - ..
620719 - This seems to align with Progress Notes originally published today on
620720 - 120925, per above. ref SDS 0 XB51 and ref SDS 0 R87N
620722 - ..
620723 - Not clear what fu egd 1028007 means. "fu egd" seems likely referring
620724 - to the next EGD procedure, but "100828007" has no evident reference
620725 - in the record.
620727 - ..
620728 - Reason for addendum unclear in the record.
620729 -
620730 - /es/ RANDALL E LEE, MD
620731 - STAFF PHYSICIAN, GASTROENTEROLOGY
620732 - Signed: 09/25/2012 15:01
620733 -
620735 - ..
620736 - 3. 09/28/2012 ADDENDUM STATUS: COMPLETED
620737 -
620738 - The patient requested that I submit a referral to Dr Stewart
620739 - at SFVA for a follow up visit, which I did today.
620740 -
620741 - /es/ RANDALL E LEE, MD
620743 - ..
620744 - This implements work plan during the meeting earlier today on
620745 - evaluating cause of reflux when laying on left side, and considering
620746 - work plan to correct the problem, shown above. ref SDS 0 HG4I
620747 -
620748 -
620749 -
620750 -
620751 -
620752 -
6208 -
SUBJECTS
Default Null Subject Account for Blank Record
6303 -
630401 - ..
630402 - Biopsy Results EDG Examination Positive Candida
630403 - Candida Positive Biopsy Results EDG Examination
630404 -
630405 - Follow up
630406 -
630407 - 4. Microscopic exam/diagnosis: (Date Spec taken: Sep 25, 2012)
630408 -
630409 - A. GASTROESOPHAGEAL JUNCTION AT 40CM (BIOPSY):
630410 - - REFLUX ESOPHAGITIS WITH NEUTROPHILS
630411 - - CARDIAC MUCOSA WITH CHRONIC INFLAMMATION
630412 - - NO INTESTINAL METAPLASIA OR DYSPLASIA IS IDENTIFIED
630414 - ..
630415 - B. ESOPHAGUS AT 38CM (BIOPSY):
630416 -
630417 - - SQUAMOUS MUCOSA WITH REFLUX ESOPHAGITIS WITH NEUTROPHILS
630418 - - NO INTESTINAL METAPLASIA OR DYSPLASIA IS IDENTIFIED
630420 - ..
630421 - C. ESOPHAGUS AT 36CM (BIOPSY):
630422 -
630423 - - SQUAMOUS MUCOSA WITH REFLUX ESOPHAGITIS WITH NEUTROPHILS
630424 - - NO INTESTINAL METAPLASIA OR DYSPLASIA IS IDENTIFIED
630425 - - POSITIVE FOR CANDIDA
630427 - ..
630428 - D. ESOPHAGUS AT 34CM (BIOPSY):
630429 -
630430 - - SQUAMOUS MUCOSA WITH REFLUX ESOPHAGITIS WITH NEUTROPHILS
630431 - - NO INTESTINAL METAPLASIA OR DYSPLASIA IS IDENTIFIED
630432 - - POSITIVE FOR CANDIDA
630434 - ..
630435 - E. ESOPHAGUS AT 32CM (BIOPSY):
630436 -
630437 - - SQUAMOUS MUCOSA WITH REFLUX ESOPHAGITIS WITH NEUTROPHILS
630438 - - NO INTESTINAL METAPLASIA OR DYSPLASIA IS IDENTIFIED
630440 - ..
630441 - F. ESOPHAGUS AT 30CM (BIOPSY):
630442 -
630443 - - SQUAMOUS MUCOSA WITH REFLUX ESOPHAGITIS WITH NEUTROPHILS
630444 - - NO INTESTINAL METAPLASIA OR DYSPLASIA IS IDENTIFIED
630445 - - POSITIVE FOR CANDIDA
630447 - ..
630448 - G. ESOPHAGUS AT 28CM (BIOPSY):
630449 -
630450 - - SQUAMOUS MUCOSA WITH REFLUX ESOPHAGITIS WITH NEUTROPHILS
630451 - - NO INTESTINAL METAPLASIA OR DYSPLASIA IS IDENTIFIED
630452 - - POSITIVE FOR CANDIDA
630453 -
630454 -
630455 -
6305 -
SUBJECTS
Default Null Subject Account for Blank Record
6403 -
640401 - ..
640402 - Letter from Doctor Results EGD Dilation and Biopsy 120925
640403 -
640404 -
640405 - 1. In Reply Refer To: Sacramento VA
640406 -
640407 - Gastroenterology
640408 - (111G/SAC)
640415 -
640416 - 28 September 2012
640421 - ..
640422 - You had an endoscopic examination of your esophagus, stomach,
640423 - and upper intestines (EGD) at the Sacramento VAMC on 25
640424 - September 2012. I'm pleased to report to you that the biopsies
640425 - showed NO cancer.
640427 - ..
640428 - The biopsies did show an infection in the esophagus due to the
640429 - trapping of food in the esophagus.
640431 - ..
640432 - I've ordered the medication fluconazole to treat the infection:
640433 - 400mg the first day, then 200mg for the next 20 days.
640435 - ..
640436 - Truly yours,
640438 - ..
640439 - Randall E. Lee, M.D., F.A.C.P.
640441 - ..
640442 - Gastroenterologist, VA NCHCS
640443 - 916-366-5339
640444 - /es/ RANDALL E LEE, MD
640445 - STAFF PHYSICIAN, GASTROENTEROLOGY
640446 - Signed: 09/28/2012 17:52
640447 -
640448 -
640449 -
6405 -
SUBJECTS
Default Null Subject Account for Blank Record
6503 -
650401 - ..
650402 - Sedation Assessment Physical Exam GI Pre-proc Provider
650403 - Physical Exam GI Pre-proc Provider Assessment for Sedation
650404 -
650405 -
650406 - 2. LOCAL TITLE: GI Pre-Proc Provider Assmnt 60440
650407 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
650408 - DATE OF NOTE: SEP 25, 2012@13:00 ENTRY DATE: SEP 25, 2012@13:09:15
650409 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
650410 - URGENCY: STATUS: COMPLETED
650411 -
650412 - *** GI Pre-Proc Provider Assmnt 60440 Has ADDENDA ***
650414 - ..
650415 - CONSCIOUS SEDATION PRE-PROCEDURE NOTE:
650416 -
650417 - 1. ASA II
650418 -
650419 - 2. MENTAL STATUS:
650420 - ALERT
650421 - ORIENTED TO PERSON, PLACE, DATE/TIME, LOCATION, AND SITUATION.
650423 - ..
650424 - 3. Diagnosis: achalasia / gerd stricture
650425 - 4. Scheduled Procedure: egd & dilation
650427 - ..
650428 - 5. Reason for the planned procedure: treatment
650430 - ..
650431 - 6. MD/DENTIST/NP ASSESSMENT:
650432 -
650433 - 1. PATIENT HISTORY:
650434 -
650435 - 1. NEURO:
650436 -
650437 - Stroke/Encephalopathy: no
650439 - ..
650440 - 2. AIRWAY:
650441 -
650442 - Prior problems with intubation: no
650443 - Recent stridor/snoring: no
650444 - Other:
650446 - ..
650447 - 3. RESP:
650448 -
650449 - Chronic Bronchitis/Emphysema: no
650450 - Asthma: no
650452 - ..
650453 - 4. Recent Infections: no
650455 - ..
650456 - 5. Other:
650457 -
650458 - NO HX OF OSA
650460 - ..
650461 - 2. INFECTIOUS DISEASE:
650462 -
650463 - 1. AIDS/Hepatitis: no
650464 -
650465 - 2. GI/GU:
650466 -
650467 - Kidney Disease: no
650468 - Liver Disease: no
650470 - ..
650471 - 3. ENDOCRINE:
650472 -
650473 - Diabetes? no
650475 - ..
650476 - 4. CV:
650477 -
650478 - HTN: no
650479 - MI/Angina: no
650480 - CHF: no
650481 - AICD/Pacemaker: no
650482 - Prosthetic Heart Valve: no
650484 - ..
650485 - 5. OTHER:
650486 - Smoking: no
650487 - ETOH: no
650489 - ..
650490 - 6. CAD CABG
650492 - ..
650493 - 7. Illicit drug use: no
650495 - ..
650496 - 8. Comments:
650498 - ..
650499 - 3. PHYSICAL ASSESSMENT:
650500 -
650501 - Vitals - most recent
650503 - ..
650504 - Temp:97.6 F [36.4 C] (09/25/2012 12:46)
650505 - BP: 118/74 (09/25/2012 12:53)
650506 - HR: 59 (09/25/2012 12:46)
650507 - RR: 16 (09/25/2012 12:46)
650508 - WT: 193 lb [87.7 kg] (09/25/2012 12:46)
650509 - HT: 66 in [167.6 cm] (09/25/2012 12:46)
650511 - ..
650512 - 4. PHYSICAL ASSESSMENT:
650513 -
650514 - Allergies: Patient has answered NKA
650516 - ..
650517 - Airway: Can patient open mouth wide? yes
650518 -
650519 - Can patient stick out tongue? yes
650520 - Restricted movement of the neck? no
650521 - Uvula fully visible when mouth open? yes
650522 -
650523 - Comments:
650525 - ..
650526 - Lungs: clear
650527 - Heart: unremarkable
650528 - Exam specific to procedure: abd benign
650530 - ..
650531 - 7. Medications:
650532 -
650533 - Active Outpatient Medications (excluding Supplies):
650535 - ..
650536 - Active Outpatient Medications Status
650537 -
650538 - 1. ROSUVASTATIN CA 20MG TAB TAKE ONE-HALF TABLET BY ACTIVE
650539 - MOUTH ONCE DAILY - TO LOWER CHOLESTEROL. REPLACES
650540 - SIMVASTATIN *USE PILL CUTTER* (APPROVED)
650541 -
650542 -
650543 -
650545 - ..
650546 - 8. Is new EKG or CXR Necessary: no
650548 - ..
650549 - 9. Pertinent Lab data:
650551 - ..
650552 - 10. I have reviewed the interim history and repeated the
650553 - relevant physical exam. There are no significant changes
650554 - compared to prior visit. If changes in medical condition
650555 - or exam are significant, list;
650557 - ..
650558 - 11. SEDATION PLAN:
650559 -
650560 - Sedation/Anesthesia options, benefits, and risks were
650561 - discussed including: nausea/vomiting, allergic reactions,
650562 - unexpected cardiac or pulmonary problems, and cardiac
650563 - arrest. Patient expressed understanding and wishes to
650564 - proceed with planned sedation/anesthesia.
650566 - ..
650567 - Did a family member or companion accompany the patient and
650568 - participate in the discussion and Interview? yes
650569 -
650570 -
650571 - 12. /es/ RANDALL E LEE, MD
650572 - STAFF PHYSICIAN, GASTROENTEROLOGY
650573 - Signed: 09/25/2012 13:11
650574 -
650575 -
650576 -
650577 -
650578 -
650579 -
650580 -
650581 -
650582 -
650583 -
650584 -
650585 -
650586 -
650587 -
650588 -
650589 -
650590 -
650591 -
650592 -
650593 -
650594 -
650595 -
650596 -
650597 -
650598 -
650599 -
650600 -
650601 -
650602 -
650603 -
650604 -
650605 -
650606 -
650607 -
650608 -
650609 -
650610 -
650611 -
650612 -
650613 -