CONTACTS
SUBJECTS
VA Achalasia Heller Myotomy Surgery Objective Improve Swallowing Req
1303 -
1303 - ..
1304 - Summary/Objective
1305 -
130501 - Follow up ref SDS 12 0000.
130502 -
130503 -
130504 -
130506 - ..
1306 -
1307 -
1308 - Progress
1309 -
130901 - Check in.
130902 -
130903 - Told Attendant will work in waiting area near Emergency Department
130904 - where there is an electrical outlet.
130905 -
130906 -
130907 -
130909 - ..
1310 -
1311 -
1312 - 1317
1313 -
131301 - Called by nurse for vitals.
131302 -
131303 - Another attendant in the reception area said she would watch computer
131304 - for a few minutes.
131306 - ..
131307 - Vitals taken....
131308 -
131309 - Weight......................... 182.4
131310 - BP............................. 133 80
131311 - HR............................. 100
131313 - ..
131314 - This seems conflicting with the record this morning, reported in case
131315 - study on 101010 0744. ref SDS 5 U48O
131317 - ..
131318 - Vitals today further conflict with meeting Doctor Lee at VA on 120925
131319 - 0900. ref SDS 12 487K
131321 - ..
131322 - Rise in blood pressure may be due to Fluconazole (that increases
131323 - effects and side effects of statins, in this case Rosuvastatin)
131324 - prescribed to treat infection on 121004, shown in case study on 101010
131325 - 0744. ref SDS 5 1W9L Fluconazole was reviewed on 121001 0820.
131326 - ref SDS 13 0450
131327 -
131328 -
131329 -
131330 -
131332 - ..
1314 -
1315 -
1316 - 1352
1317 -
131701 - Called from waiting area near Emergency Department into Clinic.
131702 -
131703 - This is fortunate to get meeting prior to 1430, so more likely to
131704 - have less traffic delays leaving the City.
131706 - ..
131707 - Doctor Vaughn - CJ enters Examination Room.
131709 - ..
131710 - The doctor asked for purpose of meeting?
131712 - ..
131713 - Issues to review...
131714 -
131715 - 1. Heller Myotomy surgery did not resolve swallowing problems.
131717 - ..
131718 - 2. OA 120601 began suffering backflow into throat laying on left
131719 - side, reported on 120925 0900. ref SDS 12 6J9G
131721 - ..
131722 - CJ asked about patient history...
131724 - ..
131725 - We reviewed the record showing...
131726 -
131727 - 1. Heller Myotomy plan surgery............... 091030 0810, ref SDS 1 2N4G
131729 - ..
131730 - 2. Heller Myotomy surgery.................... 091216 0600, ref SDS 2 KE9U
131732 - ..
131733 - 3. EGD dilation acid burn on flap............ 100305 1000, ref SDS 3 PR6P
131734 - Omeprazole 20 mg prescribed
131736 - ..
131737 - 4. EGD dilation no improvement............... 100827 0738, ref SDS 4 0466
131738 - Omeprazole 40 mg prescribed
131740 - ..
131741 - Severe swallowing problems................ 101207 1000, ref SDS 6 WH4N
131743 - ..
131744 - 5. EGD dilation flap appears healthy......... 101210 0930, ref SDS 7 XG6J
131745 - Omeprazole 80 mg prescribed
131747 - ..
131748 - 6. EGD dilation to size ring finger.......... 110429 1230, ref SDS 8 SS5R
131749 - Omeprazole 80 mg prescribed
131751 - ..
131752 - 7. EGD dilation.............................. 110819 0830, ref SDS 9 SR8M
131753 - Omeprazole 80 mg prescribed
131755 - ..
131756 - Omperazole 20 mg to lower blood
131757 - pressure.......case study on 101010....... 111201 0744, ref SDS 5 734L
131759 - ..
131760 - 8. EGD dilation 18 mm........................ 120322 1030, ref SDS 10 UH5F
131761 - Omitted steriod
131762 - Omeprazole 40 mg.......................... 120322 1030, ref SDS 10 B48L
131764 - ..
131765 - Dizzy, peripheral neuropathy.............. 120906 1100, ref SDS 11 I05F
131766 - Omperazole 20 mg
131768 - ..
131769 - 9. EGD dilation 9mm to 18 mm................. 120925 0900, ref SDS 12 TJ3N
131770 - added steriod
131771 - Omperazole 40 mg
131773 - ..
131774 - At this time having had 7 EGD Dilation procedures, with the first on
131775 - 100305, per above, ref SDS 0 DL6M, this indicates there was a change
131776 - in the scope of Heller Myotomy surgery performed 091216.
131778 - ..
131779 - CJ asked how many EGD Dilation procedures have been done? The record
131780 - shows 7 have been performed, per above. ref SDS 0 DL6M
131782 - ..
131783 - Explained recent reflux problem primarily with liquids, and when
131784 - laying on left side, which conflicts with objectives for flap,
131785 - reported on 091030 0810. ref SDS 1 OY64
131786 -
131787 - [On 121113 1100 meeting with Doctor Stewart advised that
131788 - barrium swallow test shows improved condition of esophagus
131789 - and that nothing further can be performed surgically to
131790 - resolved failed "wrap" to prevent backflow from the stomach
131791 - into the esophagus when laying on left side. ref SDS 16
131792 - EI9M
131794 - ..
131795 - CJ indicated these are important follow up issues - effectivenss of
131796 - Heller Myotomy surgery, and remedial work to improve swallowing toward
131797 - original objectives to eliminate need for pneumatic dilation, and to
131798 - prevent backflow through LESV.
131799 -
131800 -
131801 -
1319 -
SUBJECTS
Voice Problem Fluconazole Resolve Infection Esophagus Throat Reporte
3203 -
320401 - ..
320402 - Voice Problem Possibly Fluconazole Resolve Throat Infection
320403 -
320404 - CJ asked about disrupted voice problem. She feels voice is not
320405 - normal.
320407 - ..
320408 - Explained this problem is episodal, and does not occur every day.
320409 - Most recently, it may relate to elevated exercise. Another
320410 - possibility is adding Fluconazole and/or accumulated effects of
320411 - Omeprazole taken for past 3 years.
320412 -
320413 - [...below CJ's progress notes cite horse voice issue.
320414 - ref SDS 0 XU31
320416 - ..
320417 - [On 121221 0830 Doctor Poss in VA ENT Department at San
320418 - Francisco Medical Center again noticed voice disorder and
320419 - made examination for determination of causation.
320420 - ref SDS 17 WW7N
320422 - ..
320423 - Fluconazole was prescribed to resolve throat infection found in biopsy
320424 - taken with EGD Dilation procedure on 120925 0900. ref SDS 12 UN9H
320425 - Started taking Fluconazole on 121004 1529. ref SDS 14 5N3O
320427 - ..
320428 - Hiking was increased significantly during October from 97 to 270 miles
320429 - this month, shown in case study for patient history listed in the
320430 - record on 101010 0744 (see 121031). ref SDS 5 IQ7H
320431 -
320432 - [On 121024 ended treatment with Fluconazole, reported in
320433 - case study on 101010 0744, ref SDS 5 QQ7K; and within
320434 - about 1 week voice problem seemed to subside.
320435 -
320436 -
320437 -
320438 -
320439 -
320440 -
3205 -
SUBJECTS
VA Achalasia Heller Myotomy Surgery Objective Improve Swallowing Req
4203 -
4204 - 1417
420501 - ..
420502 - CJ leaves Examination Room to brief Doctor Stewart.
420503 -
420505 - ..
4206 -
4207 -
4208 - 1420
4209 -
420901 - Doctor Stewart arrives with CJ.
420902 -
420903 - The doctor advised that achalasia patients never recover normal
420904 - swallowing capability. She explained that muscle strength of the
420905 - throat has totally atrophied, and cannot be restored. Therefore,
420906 - swallowing can only occur with gravity.
420908 - ..
420909 - Doctor Stewart seemed aware that following Heller Myotomy surgery on
420910 - 091216 to improve swallowing with gravity, and lieu of pneumatic
420911 - dilation, planned in the meeting on 091030 0810, ref SDS 1 2N4G, the
420912 - patient has undergone 7 pneumatic dilation procedures, with another
420913 - scheduled for April.
420914 -
420915 - [On 121113 1100 meeting with Doctor Stewart advised that
420916 - barrium swallow test shows improved condition of esophagus
420917 - and that nothing further can be performed surgically to
420918 - resolved failed "wrap" to prevent backflow from the stomach
420919 - into the esophagus when laying on left side. ref SDS 16
420920 - EI9M
420922 - ..
420923 - Doctor Stewart corrected the record explaining she constructed a
420924 - "wrap" and not a "flap" to prevent backflow during surgery on 091216,
420925 - and planned in the meeting at the VA on 091030 0810. ref SDS 1 OY69
420927 - ..
420928 - Doctor Stewart seemed to indicate that problems of backflow through
420929 - LESV into the throat and causing drowning sensation, through the flap
420930 - constructed with Heller Myotomy surgery on 091216, should occur laying
420931 - on the right side, rather than on the left side as actually occurring,
420932 - and reported to the VA recently on 120925 0900. ref SDS 12 6J9G
420933 -
420934 - [On 121113 1100 Doctor Stewart explains that the "wrap"
420935 - which she constructed during Heller Myotomy surgery on
420936 - 091216, causes backflow (reflux) to occur laying on the
420937 - left side, rather normally on the right side. ref SDS 16
420938 - WB54
420940 - ..
420941 - Doctor Stewart recommended avoiding potato chips and crackers with
420942 - brie cheese for late night snacks - suggested fruit for snacks to
420943 - avoid backflow through the wrap into the throat.
420945 - ..
420946 - CJ recalled that primarily liquid backflows through the wrap laying on
420947 - the left side, per initial briefing above. ref SDS 0 M68I
420949 - ..
420950 - Further clarified this problem is recent within the past 3 months.
420951 - For the first several years, there was no backflow problem.
420953 - ..
420954 - Doctor Stewart seemed to indicate that in some cases repair surgery
420955 - can be effective to improve swallowing, without backflow.
420957 - ..
420958 - The doctor ordered another barium test to further evaluate the
420959 - throat.
420961 - ..
420962 - Test will be performed later this week at VA in Martinez. The doctor
420963 - asked to call her about results, and scheduling a following meeting
420964 - for further consultation.
420966 - ..
420967 - Doctor Stewart submitted a business card showing her direct line
420968 - is...
420969 -
420970 - Lygia Stewart, MD
420971 - Chief, General Surgery
420972 - Department of Surgery
420973 - US Department of Veterans Affairs
420974 - San Francisco Medical Center
420975 - 4150 Clement Street
420976 - San Francisco, CA 94121
420977 -
420978 - 415 750 6922
420980 - ..
420981 - [On 121019 1514 notified Brian in Doctor Stewart's office
420982 - that Va has not submitted notice scheduling the test.
420983 - ref SDS 15 6C9F
420985 - ..
420986 - CJ commented on usefulness of SDS record understanding patient
420987 - history, per above. ref SDS 0 4X5H
420988 -
420989 -
420990 -
4210 -
SUBJECTS
Default Null Subject Account for Blank Record
4303 -
430401 - ..
430402 - After the meeting received CJ's progress notes on the meeting today
430403 - with understandings above, and saying...
430404 -
430405 - 1. General Surgery Clinic
430406 - Site: San Francisco, CA
430407 - Date: 121016 1410
430408 - Author: Carolyn J Vaughn
430409 - Location: Surg-General Fol-Up stewart
430411 - ..
430412 - 2. Local Tital: General Surgery Clinic
430413 - Standard Tital: Surgery Outpatient Note
430414 - Date of Note: 121016 1410
430415 - Entry Date: 121016 141103
430416 - Author: Vaughn, Carolyn J
430417 - EXP Cosigner:
430418 - Urgency:
430419 - Status: Completed
430421 - ..
430422 - 3. I have discussed the patient with my attending physician,
430423 - Doctor Stewart, who agrees with my assessment and plan.
430425 - ..
430426 - 4. Vital Signs:
430427 -
430428 - 1. Height: 66" (167.6 cm) (091216 1800)
430429 - 2. Weight: 174 pounds (79.1 kg) (091216 1800)
430430 - 3. BMI: 28:1 (Overweight)
430431 - 4. BP: 122 66 (091220 0846)
430432 - 5. Resp: 16 (091220 0846)
430433 - 6. Pulse: 96 (091220 0846)
430434 - 7. O2 Sat: O96 (091220 084630)
430435 - 8. Pain: 0 (091220 0846)
430437 - ..
430438 - 5. ...[Patient...
430440 - ...is a 67 year old male with achalasia who underwent
430441 - laparoscopic Heller myotomy and Dor Fundoplication on 091216
430442 - with Doctor Stewart. Postop, the patient developed an
430443 - esophageal stricture. He has been seen by Doctor Lee of VA
430444 - Martinez for endoscopic dilation essentially every 4 momths
430445 - since surgery, for total of 7 dilations since 2010. Last
430446 - dilation was 120925, dilated to 18mm.
430448 - ..
430449 - 6. Patient reports that he has no problems swallowing liquids.
430450 - Immediately after dilation he has no trouble with any foods,
430451 - but progressively has has more trouble with solids including
430452 - meat, and potato chips. He is able to eat soft meats,
430453 - vegetables, and fish without problems.
430455 - ..
430456 - 7. He has intentional weight loss, good energy, exercises
430457 - regularly. He also notes in the past 6 months he has some
430458 - regurgitation of liquids, specifically when laying on his left
430459 - side. He denies any reflux or acid regurgitation.
430461 - ..
430462 - 8. He continues on Omeprazole 20 BID.
430464 - ..
430465 - 9. In the month prior to most recent EGD he noted a horse voice
430466 - and sore throat, EGD showed e/o candidiasis, proven by biopsy,
430467 - and patient was started on Fluconazole and continues on this
430468 - presently.
430470 - ..
430471 - Aligns with patient history, shown above. ref SDS 0 AE7K
430473 - ..
430474 - VA Progress Notes continue...
430475 -
430476 - 10. Plan from Doctor Lee was to repeat EGD and dilation in 6
430477 - months.
430479 - ..
430480 - 11. The patient presents today for any possible surgical options.
430482 - ..
430483 - 12. On exam well nourished, NAD
430484 - Abd soft, NTND.
430486 - ..
430487 - 13. A/P: 67 year old male with h/o achalasia s/p lap Heller
430488 - myotomy & Dor fundoplication now with esophageal stricture
430489 - with repeat dilatinos and now with 6 mos h/o
430490 - regurgitation/reflux while laying on L side.
430492 - ..
430493 - 14. Will order Upper GI study to see if anything surgically
430494 - treatable. Study to be done in Martinez.
430495 -
430496 - [On 121113 1100 Barrium swallow test performed and doctor
430497 - reported results show no improvement compared to prior
430498 - study. ref SDS 16 4X5H
430500 - ..
430501 - 15. Recommend dietary modifications - limit nighttime snacks or
430502 - opt for lower fat snacks that would not remain in stomach as
430503 - long and potentially worsen reflux.
430505 - ..
430506 - 16. Patient return to clinic in 3 weeks after upper GI done.
430507 -
430508 - [On 121113 1100 Doctor Stewart consulted with attending
430509 - physician who changed report improvement compared to prior
430510 - study. ref SDS 16 EI9M
430511 -
430512 - [On 121113 1100 Doctor Stewart made referral to ENT for
430513 - review horse voice disorder. ref SDS 16 8K51
430515 - ..
430516 - 17. Discussed with Doctor Stewart.
430517 -
430518 - 18. /es/ Carolyn J Vaughn
430519 - MD UC # 83395
430520 - Signed: 121016 1437
430521 -
430522 -
430523 -
430524 -
430525 -
430526 -
430527 -
430528 -
430529 -
430530 -
430531 -
430532 -
4306 -