CONTACTS
SUBJECTS
VA EGD Procedure Dilate Stricture Lower Esophageal Sphincter Valve L
5203 -
5203 - ..
5204 - Summary/Objective
5205 -
520501 - Follow up ref SDS A0 0000. ref SDS 93 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 scheduled in VA's letter dated 121107, received on
520906 - 121112 1527. ref SDS A2 K37G
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 A0 NU8L, ref SDS 93 NU8L.
521306 -
521307 - Applied pre-proc requirements for NPO after midnight, from letter on
521308 - 101015 1547. ref SDS 54 4J9L Last food was at 130109 2210.
521310 - ..
521311 - Stayed at Kathy's place last night in Sacremento. This morning, She
521312 - drove us to VA Medical Center at Mather AFB.
521314 - ..
521315 - Checked into GI Department at the customer counter.
521317 - ..
521318 - Submitted Kathy's cell phone for designated driver.
521322 - ..
521323 - Kathy signed the discharge form affirming she will be designated
521324 - driver, and responsible to facilitate no driving for 24 hours.
521326 - ..
521327 - Nurse at customer counter asked questions on patient history to verify
521328 - ready for procedure, e.g., no allergies, and NPO after midnight to
521329 - avoid conflicts with anesthesia; no health problems, e.g., no
521330 - diabetes, alcohol, cigarettes.
521332 - ..
521333 - Waited in lobby for 5 minutes.
521334 -
521336 - ..
5214 -
5215 -
5216 - 0913
5217 -
521701 - Doctor Lee called us into an examination room.
521702 -
521703 - This procedure conflicts with past practice for pre-proc preperation
521704 - performed by medical staff.
521706 - ..
521707 - The doctor's new daughter adopted last year, when he and his wife
521708 - traveled to China in December 2011, is doing well. They greatly
521709 - enjoy having a 12 year old and their new baby.
521710 -
521711 - 1. How is Doctor Lee's 12 or 13 year old handling having a 2 year
521712 - old sister, discussed during prior meeting on 120925 0900.
521713 - ref SDS A0 5S70
521715 - ..
521716 - 2. Has GI team been successful with case study to demonstrate that
521717 - local management of GI scheduling avoids mistakes and delivers
521718 - care more efficiently in less time, less expense and with
521719 - better quality, discussed during the meeting on 120925 0900.
521720 - ref SDS A0 NA4K
521722 - ..
521723 - 3. Radiology procedure scheduled 130117 0900 in VA Martinez, what
521724 - will be tested, and purpose of test, following up call from
521725 - Grace yesterday on 130108 1549. ref SDS A8 V28Q
521727 - ..
521728 - 4. Patient history review, continuing past practice from meeting
521729 - on 120925 0900. ref SDS A0 TJ3N
521730 -
521731 - a. History of swallowing disorder and medical procedures
521732 - reported on 121016 1302. ref SDS A1 PT4L
521733 -
521734 - b. Hiking and weight loss increased to 700 miles Sep - Nov,
521735 - and caused sore hip and shoulder, reported on 121130 0846.
521736 - ref SDS A4 SY4L
521738 - ..
521739 - This has improved with increased Glucosamine Chondroitin,
521740 - reported in case study on 101010 0744. ref SDS 52 RO3J
521742 - ..
521743 - c. Meeting Doctor Stewart at VA in San Francisco Medical
521744 - Center on 121016 referred from Doctor Lee evaluate improve
521745 - swallowing with less reliance on EGD dilation procedures
521746 - every 3 - 6 months. ref SDS A1 II5L
521747 -
521748 - 1. Scheduled barium swallow test ordered for morning of
521749 - 121113. ref SDS A1 JH6I
521751 - ..
521752 - 2. Voice disorder identified. ref SDS A1 AE7K
521754 - ..
521755 - 3. Reflux through LESV wrap constructed during Heller
521756 - Myotomy should be occurring when laying on right side,
521757 - rather than on left side. ref SDS A1 6O5I
521759 - ..
521760 - d. Meeting Doctor Stewart on 121113, at VA Medical Center in
521761 - San Francisco...
521762 -
521763 - 1. Barium swallow test showed no improvement from Heller
521764 - Myotomy surgery performed on 091216, ref SDS A3 4X5H;
521765 - this was changed in telecon between Doctor Stewart and
521766 - attending physician several hours later to report test
521767 - findings that LESV was improved following Heller
521768 - Myotomy surgery. ref SDS A3 EI9M
521770 - ..
521771 - 2. Barium swallow test indicates no surgical solution is
521772 - available to achieve original objectives of avoiding
521773 - reliance on continuing pneumatic dilation. ref SDS A3
521774 - EI4R
521776 - ..
521777 - 3. Reflux through LESV wrap constructed during Heller
521778 - Myotomy should be occurring when laying on left side,
521779 - rather than on right side, ref SDS A3 WB54, and
521780 - concurring with Doctor Lee's analysis in the prior
521781 - meeting at the VA in Sacramento on 120925 0900.
521782 - ref SDS A0 FO4I
521784 - ..
521785 - 4. Reflux through LESV could be caused in part by
521786 - increased hiking and weight loss to control
521787 - cholesterol. ref SDS A3 8K54
521789 - ..
521790 - 5. ENT at VA Medical Center in San Francisco referral for
521791 - evaluation of voice disorder scheduled for 121221,
521792 - shown in the record on 121113 1100. ref SDS A3 8K51
521794 - ..
521795 - 6. Scheduled following up later changed to 130122 1320,
521796 - following voice disorder and training consultation with
521797 - ENT earlier in the morning. ref SDS A3 TV8I
521798 -
521800 - ..
521801 - e. Meeting Doctor Egan in Cardiology on 121206 0900.
521802 - ref SDS A5 0001
521803 -
521804 - 1. Lab electrolytes skewed by dehydration caused by
521805 - Rosuvastatin, ordered immediate interim lab.
521806 - ref SDS A5 6K4J
521808 - ..
521809 - 2. Phase 1 clinical trial complete shows lower cholesterol
521810 - with less reliance on drugs (reduce Rosuvasttin 50%),
521811 - and more exercise hiking 700 miles prior 3 months, with
521812 - weight loss. ref SDS A5 2N4G
521814 - ..
521815 - 3. Phase 2 clinical trial approved eliminating drugs to
521816 - test lowering LDL and increasing HDL cholesterol with
521817 - reliance solely on exercise and weight loss.
521818 - ref SDS A5 OS5L
521820 - ..
521821 - 4. Test lab in 3 months, and follow up consultation to
521822 - evaluate progress. ref SDS A5 OS5L
521824 - ..
521825 - f. Interim lab on 121212. showed that reducing dehydration
521826 - by ending Rosuvastatin ordered on 121206, corrected
521827 - skewed lab results for electrolytes, ref SDS A6 KK9M,
521828 - and may further indicate exercise and weight loss can
521829 - have positive effect on lowering cholesterol.
521830 - ref SDS A6 RE7F
521832 - ..
521833 - g. Interim lab on 121212. showed BUN while still barely
521834 - within published range, has increased 60%, and so may
521835 - indicate progressing kidney issues. 121212 0941,
521836 - ref SDS A6 KK9M
521838 - ..
521839 - h. Meeting ENT Department Doctor Pross on 121221, at VA
521840 - Medical Center in San Francisco.
521841 -
521842 - 1. Testing showed no evident vocal chord disorder.
521843 - ref SDS A7 3X8I
521844 -
521845 - 2. Ordered voice training consultation scheduled for
521846 - 130122 0800, with Trish, reported on 121221 0830.
521847 - ref SDS A7 LT3Q
521849 - ..
521850 - 5. Dizziness returned in past 2 weeks, milder than originally
521851 - reported on 120815 0621. ref SDS 98 HU5K
521853 - ..
521854 - 6. Peripheral neuropathy has recurred despite ending Rosuvastatin,
521855 - reported to Doctor Egan during meeting on 121206 0900.
521856 - ref SDS A5 PK5K Severity and frequency have declined, and
521857 - issue seems controlled with increased hiking, reported
521858 - yesterday, and shown in case study on 101010 0744. ref SDS 52
521859 - RO3J
521861 - ..
521862 - 7. Rosacia or other facial rash (possibly due to increased
521863 - exercise causing persperation and exposure to sun), and cited
521864 - by Doctor Egan on 121206 0900. ref SDS A5 SU6F, has improved in
521865 - the past 2 months.
521867 - ..
521868 - 8. Sore throat has subsided entirely since ending Rosuvastatin on
521869 - 121206, which reduced dehydration.
521871 - ..
521872 - 9. Vomitting significantly reduced past 3 months taking Omeprazole
521873 - 20 mm twice per day, shown in case study on 101010 0744.
521874 - ref SDS 52 UG7K
521876 - ..
521877 - 10. Omeprazole experiment 1 pill 20 mg per day beginning 4 days ago
521878 - on 130106, shown in case study on medications, diet, vitals and
521879 - exercise on 101010 0744. ref SDS 52 AD5G No evident adverse
521880 - effects.
521882 - ..
521883 - 11. Swallowing continues significantly improved comparing patient
521884 - history of 16 severe vomitting events in case study on 120101,
521885 - ref SDS 92 UX4H, ending prior cycle on 120925, ref SDS A0 TZ4M,
521886 - following EGD and dilation 18 mm procedure at that time on
521887 - 120925 0900, ref SDS A0 XB51, and combined with triamcinolone
521888 - steriod injection to resist contraction of LESB, also performed
521889 - during procedure on 120925 0900. ref SDS A0 R87N Current cycle
521890 - ending today, case study on 120101 0900, ref SDS 92 UX4H, shows
521891 - only 4 minor vomitting events...
521892 -
521893 - 20%.................... 120928
521894 - 4%.................... 121107
521895 - 5%.................... 121128
521896 - 20%.................... 121218
521898 - ..
521899 - 12. Objective dilate LESV 20 mm and test reducing Omeprazole to 20
521900 - mm once per day with next EGD dilation in 3 - 4 months, rather
521901 - than 6 months.
521902 -
521903 - LESV Dilated
521904 - Date from - to
521905 - 130110 15 18.....triamcinolone.... ref SDS 0 Q333
521906 - 120925 15 18.....triamcinolone.... ref SDS A0 XB51
521907 - 120322 16.5 18...................... ref SDS 93 516N
521908 - 111115 16.5 18...................... ref SDS 90 IR57
521909 - 110819 15 16.5...triamcinolone.... ref SDS 87 J978
521910 - 110429 13 16.5...triamcinolone.... ref SDS 78 U23I
521911 - 110218 11 14.....triamcinolone.... ref SDS 73 AA5O
521912 - 101210 11 14...................... ref SDS 66 H347
521913 - 100827 11 15...................... ref SDS 49 JE6X
521914 - 100305 11 15...................... ref SDS 42 WR6L
521916 - ..
521917 - [...below on 130110 0900 Progress Notes report Doctor Lee
521918 - continued adding triamcinolone injection today, to resist
521919 - contraction of LESV that aids swallowing to avoid
521920 - vomitting, ref SDS 0 Q34P, and aligns with prior practice
521921 - on 110429, continuing injections when experience showed
521922 - triamcinolone steriod injection was effective. ref SDS 78
521923 - SS5N Continued response to treatment supported continuing
521924 - triamcinolone injection protocol for the next cycle on
521925 - 110819. ref SDS 87 J985
521926 -
521927 -
521928 -
521930 - ..
5220 -
5221 -
5222 - 0519
5223 -
522301 - Dilated 18 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee
522302 - Meeting Doctor Lee Present Results EGD Dilation Procedure
522303 - Results EGD Dilation Procedure Meeting Doctor Lee Present
522304 -
522305 - Follow up ref SDS A0 SR6K, ref SDS 94 SR6K.
522306 -
522307 - Doctor Lee reported LESV contracted to only 15 mm. This is
522308 - significant improvement compared to prior contractions over 3 months.
522310 - ..
522311 - He dilated LESV to 18 mm during the procedure this afternoon.
522312 - ref SDS 0 Q333, and injected triamcinolone steriod again. ref SDS 0
522313 - Q34P
522314 -
522315 - LESV Dilated
522316 - Date from - to
522317 - 130110 15 18.....triamcinolone.... ref SDS 0 Q333
522318 - 120925 15 18.....triamcinolone.... ref SDS A0 XB51
522319 - 120322 16.5 18...................... ref SDS 93 516N
522320 - 111115 16.5 18...................... ref SDS 90 IR57
522321 - 110819 15 16.5...triamcinolone.... ref SDS 87 J978
522322 - 110429 13 16.5...triamcinolone.... ref SDS 78 U23I
522323 - 110218 11 14.....triamcinolone.... ref SDS 73 AA5O
522324 - 101210 11 14...................... ref SDS 66 H347
522325 - 100827 11 15...................... ref SDS 49 JE6X
522326 - 100305 11 15...................... ref SDS 42 WR6L
522327 -
522328 -
522329 -
522330 -
522331 -
522332 -
522333 -
5224 -
SUBJECTS
Default Null Subject Account for Blank Record
5303 -
530401 - ..
530402 - Medical Chart Progress Notes
530403 - Chronic Swallowing Requires Dilation Conflicts Objectives Surgery
530404 -
530405 - Follow up ref SDS A0 QF6L, ref SDS 90 QF6L, ref SDS 86 QF6L.
530407 - ..
530408 - VA medical chart in pdf format is stored on...
530409 -
530410 - F:\05\00003\SM\CC\AGMJ\20130110-090014\welch_022513.pdf
530411 -
530412 - 1. LOCAL TITLE: EGD 60111
530413 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
530414 - DATE OF NOTE: JAN 10, 2013@09:00 ENTRY DATE: JAN 11, 2013@10:48:14
530415 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
530416 - URGENCY: STATUS: COMPLETED
530418 - ..
530419 - 2. PATIENT NAME: WELCH, RODNEY CHARLES
530420 - DATE OF BIRTH: 03/01/1945
530422 - ..
530423 - 3. PROCEDURES:
530424 -
530425 - 1. Esophagogastroduodenoscopy.
530426 - 2. TTS balloon dilation of distal esophagus.
530427 - 3. Endoscopic injection of triamcinolone.
530429 - ..
530430 - 4. ATTENDING PHYSICIAN:
530431 - Randall E. Lee, M.D.
530433 - ..
530434 - 5. INDICATIONS:
530437 -
530438 - 1. 67-year-old man with a history of achalasia. He underwent
530439 - laparoscopic myotomy and fundoplication at San Francisco VA
530440 - Medical Center. He subsequently developed acid reflux and
530441 - a distal esophageal stricture that has required repeat
530442 - endoscopic dilations.
530444 - ..
530445 - 2. His last EGD and dilation was in 09/25/2012, at which time,
530446 - his stricture was dilated from 15 to 18 mm and 4 mL of
530447 - triamcinolone acetate with a concentration of 40 mg/mL was
530448 - injected into the distal esophageal stricture.
530450 - ..
530451 - This aligns with Progress Notes on 120925 0900. ref SDS A0 XB51
530452 -
530453 - [On 130416 1100 during next meeting reviewed favorable
530454 - results, ref SDS B2 MT6F, of CT test, on 130117 0900,
530455 - ref SDS B0 HR98, showing significant improvement
530456 - reducing esophageal swelling, ref SDS B0 OH6G; discussed
530457 - analysis Doctor Stewart finding significant resolution
530458 - of achalasia. ref SDS B1 03H6
530460 - ..
530461 - Progress Notes procedure on 130110 continue...
530462 -
530463 - 3. Biopsies showed no evidence of intestinal metaplasia or
530464 - dysplasia.
530466 - ..
530467 - This aligns with Progress Notes addendum showing biopsy finding no
530468 - evidence of cancer, reported on 120925 0900. ref SDS A0 E67F
530470 - ..
530471 - Biopsy found specimens CDFG positive for candida. ref SDS A0 1U6L
530473 - ..
530474 - Progress Notes procedure on 130110 continue...
530475 -
530476 - 4. He is now here for a reevaluation. In the interim, he noted
530477 - that he believes his swallowing ability has been fairly
530478 - consistently improved since his last dilation. He had 3
530479 - episodes of vomiting, which he believes is an improvement
530480 - from previous.
530482 - ..
530483 - This aligns with report to doctor earlier today, and prior to EGD
530484 - dilation procedure, as shown above. ref SDS 0 SE7K
530486 - ..
530487 - Progress Notes procedure on 130110 continue...
530488 -
530489 - 6. CONSENT:
530490 -
530491 - The risks, benefits, and alternatives to this procedure
530492 - including but not limited to the risks of bleeding and bowel
530493 - perforation were explained to the patient. The patient
530494 - understood and provided written informed consent.
530496 - ..
530497 - 7. INTRAVENOUS MEDICATIONS:
530498 -
530499 - 1. Diphenhydramine 50 mg.
530500 - 2. Fentanyl 100 mcg.
530501 - 3. Midazolam 4 mg.
530503 - ..
530504 - 8. PROCEDURE:
530505 -
530506 - 1. In the Sacramento VA GI Endoscopy Unit, the patient was
530507 - placed in the left lateral decubitus position.
530509 - ..
530510 - 2. Oxygen at 2 liters per minute by nasal cannula was
530511 - administered.
530513 - ..
530514 - 3. Continuous oximetric and hemodynamic monitoring was
530515 - initiated.
530517 - ..
530518 - 4. Intravenous sedation was administered in divided doses.
530520 - ..
530521 - 5. After a bite block was placed in the patient's mouth, an
530522 - Olympus GIF-H180 video gastroscope was advanced under
530523 - direct vision into the esophagus.
530525 - ..
530526 - 6. A small amount of retained saliva within the esophagus was
530527 - easily irrigated and suctioned away.
530529 - ..
530530 - 7. At approximately 40 cm there was esophageal narrowing,
530531 - which did not impede passage of the diagnostic endoscope.
530533 - ..
530534 - 8. The endoscope was then advanced into the descending
530535 - duodenum. The retroflexed views of the incisura, fundus,
530536 - and cardia were performed.
530538 - ..
530539 - 9. A TTS balloon dilator was advanced across the distal
530540 - esophagus and inflated to 15 mm. The balloon engaged the
530541 - esophagus at that size, but no mucosal damage was
530542 - identified. The balloon was then inflated sequentially to
530543 - 16.5 then 18 mm and as visualized through the balloon,
530544 - mucosal tearing was noted at 16.5 and 18 mm.
530545 -
530546 - LESV Dilated
530547 - Date from - to
530548 - 130110 15 18.....triamcinolone.... ref SDS 0 Q333
530549 - 120925 15 18.....triamcinolone.... ref SDS A0 XB51
530550 - 120322 16.5 18...................... ref SDS 93 516N
530551 - 111115 16.5 18...................... ref SDS 90 IR57
530552 - 110819 15 16.5...triamcinolone.... ref SDS 87 J978
530553 - 110429 13 16.5...triamcinolone.... ref SDS 78 U23I
530554 - 110218 11 14.....triamcinolone.... ref SDS 73 AA5O
530555 - 101210 11 14...................... ref SDS 66 H347
530556 - 100827 11 15...................... ref SDS 49 JE6X
530557 - 100305 11 15...................... ref SDS 42 WR6L
530559 - ..
530560 - [On 130416 1100 LESV dilated again from 18 to 18 mm,
530561 - indicating minimal contraction with triamcinolone steriod
530562 - injections. ref SDS B3 Y850
530564 - ..
530565 - 10. The balloon was then deflated, removed, and approximately 3
530566 - mL of triamcinolone acetate at a concentration of 40 mg/mL
530567 - were injected into the areas of mucosal tearing.
530569 - ..
530570 - Continuing triamcinolone steriod injection today, aligns with the
530571 - record showing this treatment combined with Omeprazole and dilation
530572 - has been effective resisting contraction of LESV over prior cycle
530573 - shown by case study today listing only 4 episodes of mild vomitting
530574 - compared to 16 severe events during prior period ending on 120925,
530575 - above. ref SDS 0 SE7K
530577 - ..
530578 - Adding triamcinolone injection today, aligns with prior practice on
530579 - 110429, continuing injections when experience showed the protocol is
530580 - effective. ref SDS 78 SS5N As well, continued response to treatment
530581 - and without adverse side effects supported continuing triamcinolone
530582 - protocol for the next cycle on 110819. ref SDS 87 J985
530583 -
530584 - [On 130416 1100 during next meeting reviewed favorable
530585 - results, ref SDS B2 MT6F, of CT test, on 130117 0900,
530586 - ref SDS B0 HR98, showing significant improvement
530587 - reducing esophageal swelling, ref SDS B0 OH6G; discussed
530588 - analysis Doctor Stewart finding significant resolution
530589 - of achalasia. ref SDS B1 03H6
530590 -
530592 - ..
530593 - Progress Notes procedure on 130110 continue...
530594 -
530595 - 11. The stomach was then decompressed and the gastroscope
530596 - removed.
530598 - ..
530599 - 9. COMPLICATIONS:
530600 -
530601 - None.
530603 - ..
530604 - 10. FINDINGS:
530605 -
530606 - 1. Previous area of esophageal stricture again identified at
530607 - approximately 40 cm. This area is coincident with the
530608 - gastroesophageal junction. Initial estimation of the
530609 - starting diameter is between 14 and 15 mm.
530611 - ..
530612 - 2. Atonic esophageal body with retained material, but without
530613 - friable mucosa.
530615 - ..
530616 - 3. Distorted fundus consistent with known fundoplication.
530618 - ..
530619 - 4. Normal pylorus.
530621 - ..
530622 - 5. Normal duodenum to D2.
530624 - ..
530625 - 11. IMPRESSION:
530626 -
530627 - 1. Gastroesophageal reflux stricture with minor recurrence
530628 - from prior examination and dilation of September 2012.
530629 - Triamcinolone acetate appears to have reduced the
530630 - progression of the stricture.
530632 - ..
530633 - Triamcinolone steriod injection effective resisting contraction of
530634 - LESV over prior cycle shown by case study today listing only 4
530635 - episodes of mild vomitting compared to 16 severe events during prior
530636 - period ending on 120925, above. ref SDS 0 SE7K
530638 - ..
530639 - Triamcinolone steriod injection today, aligns with prior practice on
530640 - 110429, continuing injections based on impression the protocol is
530641 - effective resisting contraction of LESV that aids swallowing and
530642 - reduces vomitting. ref SDS 78 SS5N As well, continued response to
530643 - treatment and without adverse side effects supported continuing
530644 - triamcinolone protocol for the next cycle on 110819. ref SDS 87 J985
530645 - By the same reasoning, injecting triamcinolone steriod today appears
530646 - likely to reduce progression of stricture over the next cycle.
530647 -
530648 - [On 130416 1100 during next meeting reviewed favorable
530649 - results, ref SDS B2 MT6F, of CT test, on 130117 0900,
530650 - ref SDS B0 HR98, showing significant improvement
530651 - reducing esophageal swelling, ref SDS B0 OH6G; discussed
530652 - analysis Doctor Stewart finding significant resolution
530653 - of achalasia. ref SDS B1 03H6
530655 - ..
530656 - Progress Notes procedure on 130110 continue...
530657 -
530658 - 2. Atonic esophageal body consistent with known diagnosis of
530659 - achalasia.
530661 - ..
530662 - 3. Fundoplication.
530664 - ..
530665 - 12. RECOMMENDATIONS:
530666 -
530667 - 1. Continue omeprazole 20 mg twice daily.
530668 - 2. Repeat EGD and dilation in approximately 4 months.
530669 -
530671 - ..
530672 - 13. DISPOSITION:
530673 -
530674 - 1. The patient was observed in the Recovery Room and then
530675 - discharged to home with a companion.
530676 -
530677 - 2. I reviewed the endoscopic findings with the patient prior
530678 - to discharge.
530680 - ..
530681 - 14. TIME START:
530682 - 1101 hours.
530683 - TIME END:
530684 - 1114 hours.
530685 - D: 01/10/2013
530686 - T: 01/10/2013
530687 - Job number: 1062743
530688 - MKG/CMTS
530689 - $end:
530690 - /es/ RANDALL E LEE, MD
530691 - STAFF PHYSICIAN, GASTROENTEROLOGY
530692 - Signed: 02/19/2013 10:05
530693 -
530694 -
530695 -
530696 -
530697 -
530698 -
530699 -
530700 -
530701 -
530702 -
530703 -
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5308 -