CONTACTS
SUBJECTS
Voice Problem Throat Examination No Infection No Virus Larynx No Med
2603 -
2603 - ..
2604 - Summary/Objective
2605 -
260501 - Follow up ref SDS 23 0000. ref SDS 22 0000.
260502 -
260503 - ENT examination found no evident medical cause for voice disorder.
260504 - ref SDS 0 379O Initial theory that voice disorder caused by weak
260505 - vocal chords due to minimal use. ref SDS 0 LS6W VA scheduled voice
260506 - therapy next month on 130114, to strengthen vocal chords. ref SDS 0
260507 - G34L
260508 -
260509 -
260511 - ..
2606 -
2607 -
2608 - Progress
2609 -
260901 - Up at 0410, made the bed and washed cloths. Transferred files from
260902 - c18 to c16. Showered and brushed teeth.
260903 -
260905 - ..
2610 -
2611 -
2612 - 0510
2613 -
261301 - Departed Concord.
261302 -
261303 - Traffic much heavier at this hour than 5 years ago, when we started
261304 - driving to San Francisco for meetings with UCSF to get help for Millie
261305 - to recover from breast cancer, e.g., on 070322 0830. ref SDS 1 407N
261307 - ..
261308 - This morning drove through the park to US highway 1, and up past the
261309 - Cliff House to Geary and turned left on 42nd street. Had to park in
261310 - handicap lane, because even at this hour most of the non-handicap
261311 - parking lanes are taken, and those that are not taken are too narrow
261312 - for a car, because cars on either side parked too close or even across
261313 - the dividing line.
261314 -
261316 - ..
2614 -
2615 -
2616 - 0610
2617 -
261701 - Arrived at VA. Cafateria is closed until 0630. Working in main
261702 - lobby next to ER, and across from clinic modules 1 & 2. Chairs and
261703 - tables have been moved against the wall for cleaning the floor, and
261704 - have not yet been restored. There are two patients waiting for care.
261706 - ..
261707 - Re-organized the seating and tables to work here for an hour or so,
261708 - before going to the cafeteria.
261709 -
261711 - ..
2618 -
2619 -
2620 - 0622
2621 -
262101 - Patient just complained about "blocking traffic." He was unable to
262102 - walk past the table, and so had to walk to the other end of the
262103 - seating in order to sit next to a friend.
262104 -
262105 -
262106 -
262108 - ..
2622 -
2623 -
2624 - 0830
2625 -
262501 - Patient History Esophagus Surgery and EGD Dilations
262502 -
262503 - Follow up ref SDS 23 0001, ref SDS 22 0001.
262504 -
262505 - Patient history previously listed on 121016 1302. ref SDS 19 XS62
262506 -
262507 - 1. Heller Myotomy plan surgery............... 091030 0810, ref SDS 3 2N4G
262508 - Resolve achalasia swallowing
262509 - problem
262511 - ..
262512 - 2. Heller Myotomy surgery.................... 091216 0600, ref SDS 4 KE9U
262513 -
262514 - Progress notes surgery shown on........... 100928 0706, ref SDS 7 SO4N
262515 - and citing operation report shown in
262516 - VA records. ref DRP 1 YX6L
262517 -
262519 - ..
262520 - Post surgery history...
262522 - ..
262523 - 1. EGD dilation acid burn on flap............ 100305 1000, ref SDS 5 PR6P
262524 - Omeprazole 20 mg prescribed
262526 - ..
262527 - 2. EGD dilation no improvement............... 100827 0738, ref SDS 6 0466
262528 - Omeprazole 40 mg prescribed
262530 - ..
262531 - Severe swallowing problems................ 101207 1000, ref SDS 9 WH4N
262533 - ..
262534 - 3. EGD dilation wrap appears healthy......... 101210 0930, ref SDS 10 XG6J
262535 - Omeprazole 80 mg prescribed
262537 - ..
262538 - 4. EGD dilation to size ring finger.......... 110429 1230, ref SDS 12 SS5R
262539 - Omeprazole 80 mg prescribed
262541 - ..
262542 - 5. EGD dilation.............................. 110819 0830, ref SDS 13 SRM
262543 - Omeprazole 80 mg prescribed
262545 - ..
262546 - Omperazole 20 mg to lower blood
262547 - pressure.......case study on 101010....... 111201 0744, ref SDS 8 734L
262549 - ..
262550 - 6. EGD dilation 18 mm........................ 120322 1030, ref SDS 14 UH5F
262551 - Omitted steriod
262552 - Omeprazole 40 mg.......................... 120322 1030, ref SDS 14 B48L
262554 - ..
262555 - Dizzy, peripheral neuropathy.............. 120906 1100, ref SDS 15 I05F
262556 - Omperazole 20 mg
262558 - ..
262559 - 7. EGD dilation 9mm to 18 mm................. 120925 0900, ref SDS 16 TJ3N
262560 - added steriod
262561 - Omperazole 40 mg
262563 - ..
262564 - 8. EGD dilation scheduled.................... 130110
262565 -
262566 -
262568 - ..
262569 - Voice Disorder Medical History and Referral to ENT
262570 -
262571 -
262572 - 1. Biopsy EDG Dilation procedure
262573 - Doctor Lee VA Sacramento.................. 120925 0900, ref SDS 16 UN6K
262574 -
262575 - 2. Fluconazole begun to treat exophagus
262576 - infection candida......................... 121004 1529, ref SDS 18 5N3O
262578 - ..
262579 - 3. Meeting CJ and Doctor Stewart review
262580 - surgery options accomplish objectives
262581 - Heller Myotomy surgery to improve
262582 - swallowing without further EGD
262583 - Dilation procedures....................... 121016 1302, ref SDS 19 M68I
262585 - ..
262586 - 4. Voice disorder identified during
262587 - examination by CJ......................... 121016 1302, ref SDS 19 AE7K
262589 - ..
262590 - 5. ENT referral by Doctor Stewart............ 121113 1100, ref SDS 22 8K51
262592 - ..
262593 - 6. ENT scheduled meeting 121221.............. 121115 1600, ref SDS 23 4X5H
262594 -
262595 -
262597 - ..
262598 - Agenda Meeting ENT
262599 -
262600 - Meeting with Doctor Pross.
262602 - ..
262603 - Doctor Seth Pross, MD ENT Surgery, reviewed patient history, including
262604 - EGD and Dilation procedures.
262605 -
262606 - 1. Patient history achalasia............... ref SDS 0 6E3M
262608 - ..
262609 - 2. EGD and Dilations (7) since 2010........ ref SDS 0 4F6K
262611 - ..
262612 - 3. Doctor Stewart considers hiking may
262613 - cause reflux that infects vocal
262614 - chords................................. 121113 1100, ref SDS 22 8K51
262616 - ..
262617 - Doctor Pross said he noticed voice disorder this morning, that was
262618 - previously cited by CJ in a meeting at the VA on 121016 1302.
262619 - ref SDS 19 AE7K
262621 - ..
262622 - The doctor asked about current medications.
262624 - ..
262625 - Omeprazole 20 mg twice a day is the only treatment currently
262626 - prescribed.
262628 - ..
262629 - Doctor Pross described Omeprazole as a...
262630 -
262631 - proton pump inhibitor (PPI)
262633 - ..
262634 - Doctor Pross made examination. He used an instrument to examine both
262635 - ears, and said there is no evident disorder. He tested eyes by moving
262636 - his finger left and right, up and down. He used an instrument to
262637 - further test eyes. No evident disorder was found. Additional
262638 - clinical examination of the throat found no medical problems to
262639 - explain voice disorder.
262641 - ..
262642 - He said there is no evident cause of voice problems.
262644 - ..
262645 - The doctor moved the meeting down the hall to the office of voice
262646 - therapy. We met with Trish Cavanaugh.
262648 - ..
262649 - Trish performed video tests shows the throat (pharynx) with larynx and
262650 - vocal chords in action while speaking.
262652 - ..
262653 - After the test Doctor Pross joined the meeting again.
262655 - ..
262656 - Doctor Pross and Trish advised that there is no evident disorder in the
262657 - throat and specifically in the larynx and vocal chords that cause
262658 - voice disorder. The doctor said there is no evidence of virus,
262659 - infection, nor swelling. Trish concurred. They advised that the
262660 - throat appears in good order.
262662 - ..
262663 - They showed the video of the pharynx with the larynx and vocal chords
262664 - moving while making sounds.
262666 - ..
262667 - Trish explained the throat is divided into passages for food and
262668 - liquid to pass into the esophagus and into the stomach, and there is a
262669 - second passage for air to flow into the lungs. A valve, possibly the
262670 - Upper Esophageal Sphincter valve - UESV), regulates this flow so that
262671 - when swallowing, the air passage is closed and when breathing flow
262672 - from the mouth into the esophagus is closed.
262674 - ..
262675 - Research on the Internet after the meeting found...
262676 -
262677 - Webmd
262678 - Image Collection Human Anatomy...
262679 -
262680 - http://www.webmd.com/digestive-disorders/picture-of-the-esophagus
262682 - ..
262683 - The upper esophageal sphincter (UES) [...valve...] is a bundle
262684 - of muscles at the top of the esophagus. The muscles of the UES
262685 - are under conscious control, used when breathing, eating,
262686 - belching, and vomiting. They keep food and secretions from
262687 - going down the windpipe.
262689 - ..
262690 - The throat with the vocal chords in motion actually appears pristine,
262691 - without any hint of blemish or malady.
262692 -
262693 -
262694 -
2627 -
SUBJECTS
Voice Disorder Speech Therapy Schedule 130114 Correct Vocal Chords W
4303 -
430401 - ..
430402 - Vocal Disorder Correlate Patient History
430403 -
430404 - Trish and Doctor Pross considered causes of voice disorder this
430405 - morning.
430407 - ..
430408 - They asked about singing, and explained singers suffer voice disorder
430409 - from overstressing vocal chords.
430411 - ..
430412 - There is no patient history of singing.
430414 - ..
430415 - Trish asked about work and home life?
430417 - ..
430418 - Explained living and working alone, since Millie died on 100729. The
430419 - doctor asked about phone calls, meetings, interacting with people?
430421 - ..
430422 - Explained work is solitary, and so does not involve a lot of talking,
430423 - cited in a letter to Kathy on 110331 0138, ref SDS 11 TF8V, unlike
430424 - years ago, when most of the work was talking and writing, also, cited.
430425 - ref SDS 11 TF4S Now, it's mainly writing.
430426 -
430428 - ..
430429 - Vocal Chords Weak Because Minimal Use
430430 -
430431 - Their initial theory seems to be something along the lines that living
430432 - alone and doing little talking from working continually on the
430433 - computer, the vocal chords, which are a muscle, have become weak from
430434 - lack of use.
430436 - ..
430437 - This seems somewhat conflicting with patient history of normal speech
430438 - without any evident pattern of voice disorder, but rather random
430439 - occurrance, i.e., often the voice is normal, but sometimes and most
430440 - notably within the past 3 - 4 months, voice disorder has occurred.
430441 - The team's theory aligns well with patient history of voice problems
430442 - during long telephone discussions, in that vocal chords weakened from
430443 - low use become tired and so function poorly.
430444 -
430445 -
430447 - ..
430448 - Voice Therapy Breathing Exercises Prescribed
430449 -
430450 - Trish advised that she can provide voice therapy with exercises to
430451 - improve breathing and strengthen vocal chords.
430453 - ..
430454 - Doctor Pross recommended doing the therapy and then scheduling another
430455 - meeting in several months to compare with the test today. If
430456 - differences appear in the tests showing changed physiology, this may
430457 - provide guidance on gradual deterioation occuring that is not evident
430458 - today. Alternatively, therapy may complete resolve the current issue.
430460 - ..
430461 - Trish scheduled a meeting for voice therapy on 130114 at 0830 to meet
430462 - for therapy.
430464 - ..
430465 - She can adjust this date to accomodate change in schedule.
430472 - ..
430473 - [On 121226 0742 at 1424 changed meeting with Trish in ENT
430474 - for voice therapy on 130122 0800. ref SDS 25 0I4G
430475 -
430476 -
430477 -
430478 -
430479 -
430480 -
430481 -
430482 -
4305 -
SUBJECTS
Default Null Subject Account for Blank Record
4403 -
440401 - ..
440402 - Medical Chart Progress Notes
440403 -
440404 -
440405 - 1. ENT Clinic Consult Note (SURG)
440406 - Site: San Francisco, CA
440408 - ..
440409 - 2. Date........................... 2012 12 21 0804
440411 - ..
440412 - 3. Author......................... Seth Pross
440414 - ..
440415 - 4. Location....................... ENT-Clinic
440417 - ..
440418 - 5. Local Title: ENT Clinic Consult Note (Surg)
440419 - Standard Title: Otolaryngology Outpatient Consult
440420 - Date of Note: Dec 21, 2012 @ 0804
440421 - Entry Date: Dec 21, 2012 @ 080436
440422 - Author: Pross, Seth
440423 - EXP Cosigner:
440424 - Urgency:
440425 - Status: Completed
440427 - ..
440428 - 6. I have discussed the patient with my attending physician,
440429 - Doctor Chang who agrees with my assessment and treatment plan.
440431 - ..
440432 - 7. Date: December 21, 2012 0804
440434 - ..
440435 - 8. Patent's age.............................. 67
440437 - ..
440438 - 9. Medical History
440439 -
440440 - Computerized Problem List is the source for the following:
440441 -
440442 - 1. Espphageal Achalasia * (ICD-9-CM 540.0)
440443 - 2009 12 08 Tabrizzi, Ranna
440445 - ..
440446 - 10. History of Present Illness:
440447 -
440448 - 1. 67 year old man with PMH significant for CAD s/p CABG and
440449 - achalasia s/p Heller myotomy both in 2009 as well as
440450 - several more recent desphageal dilations who is referred to
440451 - the ENT clinic for evaluation of horseness. The patient
440452 - states that his horseness began a couple months ago. He
440453 - states that his voice fluctuates from normal to "scratchy"
440454 - during the day. He feels that if he is on a long phone
440455 - call his voice gets worse. He works alone most of the day
440456 - as a computer programmer and doesn't feel that he
440457 - over-utilizes his voice. He is a never smoker. He feels
440458 - that his symptoms may be worse after hiking which he does
440459 - daily.
440461 - ..
440462 - 2. He notes that if he eats too quickly he will vomit and
440463 - occassionaly feel like he is choking but those symptoms are
440464 - not associated with coughing. He is able to drink thin
440465 - liquids without difficulty except while laying on his side
440466 - He currently uses a PPI twice daily.
440468 - ..
440469 - 11. Patient Surgery History (PSH)
440470 -
440471 - 1. CABG................................ 091022, ref SDS 2 PQWU
440472 - 2. Heller Myotomy...................... 091216, ref SDS 4 KE9U
440473 - 3. Esophageal dilations 7 since........ 100305, ref SDS 5 034E
440474 - Last dilation to 18 mm.............. 120925, ref SDS 16 K37G
440476 - ..
440477 - 12. Tests
440478 -
440479 - 1. Barium Swallow...................... 121113, ref SDS 22 4X5H
440480 -
440481 - Impression
440482 -
440483 - Persistently narrowed gastroesophageal junction which
440484 - appears improved as compared to prior from 091218 with
440485 - dilated distal esophagus.
440487 - ..
440488 - 13. Medications:
440489 -
440490 - 1. Omeprazole 20 mg PO BID
440492 - ..
440493 - 14. Tobacco................................. Never
440495 - ..
440496 - 15. ETOH:..................... beer once per month
440498 - ..
440499 - 16. Allergies or Drug Reactions.............
440500 -
440501 - Patient has answered NKA
440503 - ..
440504 - 17. ENT Exam:
440505 -
440506 - 1. A&OX3, PERR1, EOMI, FN 1/6 on HB scale bilaterally, SILT v1-v3
440507 -
440508 - 2. Ears: Normal pinnae, patent EACs, intact TMs bilaterally
440509 -
440510 - 3. Nose: No external deformaties
440512 - ..
440513 - 4. OC/OP: MMM, no masses or lesions. Symetric palatal rise
440515 - ..
440516 - 5. Neck: Moderate roughness, No breathiness, moderate strain,
440517 - which fluctuates sentence to sentence with vocal
440518 - cracks/squeeks. Poor airflow at times. No stridor
440520 - ..
440521 - 6. Rigid laryngoscopy with stroboscopy performed by SLP:
440522 -
440523 - 1. No pooling of secretions in pyriform sinuses or valecula
440524 -
440525 - 2. epiglottis mucosa crisp
440526 -
440527 - 3. full abduction and adduction of the true vocal fold
440528 -
440529 - 4. complete glottid close
440530 -
440531 - 5. intact mucosal wave
440532 -
440533 - 6. no mucosal lesions of the TVFs
440534 -
440535 - 7. no significant vocal fold atrophy
440536 -
440537 - 8. no significant supraglottic squeeze
440538 -
440539 - 9. mild interarytenoid banding
440541 - ..
440542 - 18. Assessment/Plan
440543 -
440544 - 1. 67 year old man with history of achalasia s/p Heller
440545 - myotomy and new fluctuating moderate dysphonia.
440546 -
440547 - 2. Laryngoscopy shows no concerning lesions or dysfunction.
440549 - ..
440550 - 3. Acid reflux may be contributing to his symptoms but he is
440551 - currently on maximal medical management and being followed
440552 - by both general surgery and gastroenterology.
440554 - ..
440555 - 4. He will likely benefit from voice therapy with instructions
440556 - on more appropriate laryngeal use. He has agreed to trial
440557 - voice therapy. If his symptoms worsen or do not improve in
440558 - the coming months we would be happy to see him again for
440559 - repeat laryngoscopy.
440560 -
440561 - /es/ Seth Pross
440562 - PGY3 Otolaryngology - Head and Neck Surg UC # 80366
440563 - Signed........................... 2012 12 21 0856
440564 -
440565 -
440566 -
440567 -
440568 -
440569 -
440570 -
440571 -
440572 -
440573 -
4406 -