THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com
S U M M A R Y
DIARY: December 21, 2012 08:30 AM Friday;
Rod Welch
VA SF Medical Center ENT meeting on voice throat problem.
1...Summary/Objective
2...Patient History Esophagus Surgery and EGD Dilations
3...Voice Disorder Medical History and Referral to ENT
4...Agenda Meeting ENT
5...Vocal Disorder Correlate Patient History
6...Vocal Chords Weak Because Minimal Use
7...Voice Therapy Breathing Exercises Prescribed
8...Medical Chart Progress Notes
..............
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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 -