CONTACTS
SUBJECTS
Meeting Delayed 2 Hours Surgery Department VA Medical Center San Fra
0903 -
0903 - ..
0904 - Summary/Objective
0905 -
090501 - Follow up ref SDS 19 0000. ref SDS 17 0000.
090502 -
090503 -
090504 -
090506 - ..
0906 -
0907 -
0908 - Background
0909 -
090901 - On 121016 background achalasia, ref SDS 13 HS7L, meeting Doctor Stewart
090902 - on achalasia, ref SDS 13 AE9G, and schedule barium swallow test
090903 - evaulate surgery eliminate dilation procedures. ref SDS 13 FN4G
090905 - ..
090906 - On 121113 1100 radiology barium swallow CT test. ref SDS 14 4X5H
090908 - ..
090909 - On 121113 1330 meeting Doctor Stewart review barium swallow test on
090910 - resolving achalasia. ref SDS 14 EI9M
090912 - ..
090913 - On 130110 0900 EGD Dilation Doctor Lee VA Sacramento resolve
090914 - achalasia. 130110 0900, ref SDS 18 RG9K
090916 - ..
090917 - On 130107 VA called left message procedure scheduled, and to call back
090918 - for details. ref SDS 16 RY5H Called back and left message that VA's
090919 - earlier call was returned.
090921 - ..
090922 - On 130108 VA called and advised medical procedure scheduled on 130117
090923 - 0900 in Radiology Department at VA in Martinez. ref SDS 17 T068 Grace
090924 - will try to determine what procedure has been ordere, who ordered the
090925 - work, and why.
090927 - ..
090928 - Grace called back and said Doctor Lee ordered the test.
090930 - ..
090931 - On 130110 Doctor Lee said he ordered another barium swallow test.
090932 - This will compare results on 121113 1100. ref SDS 14 4X5H with
090933 - conditions after EDG dilation on 130110.
090935 - ..
090936 - On 130117 0900 radiology barium swallow CT test. 130117 0900,
090937 - ref SDS 19 LM8K
090939 - ..
090940 - On 130117 0900 at 2315 letter to Isagani notifying Doctor Stewart of
090941 - new radiology barium swallow CT test following EGD Dilation procedure
090942 - on 130110, and to compare with prior tests to evaluate progress
090943 - recovering from achalasia. ref SDS 19 LT4M
090944 -
090945 -
090946 -
090947 -
090949 - ..
0910 -
0911 -
0912 - Progress
0913 -
091301 - This morning at 0750 met with Doctor Elaine Tseng, attending physician
091302 - for CABG 4x heart bypass surgery on 091022 0700. ref SDS 3 PQWU The
091303 - doctor was walking down the hallway in the surgery department.
091305 - ..
091306 - Took the opportunity to thank Doctor Tseng for successful heart
091307 - surgery 3 years ago.
091309 - ..
091310 - The doctor was pleased with evident good recovery and continued good
091311 - health of former patient. Aligns with case study on exercise, vitals,
091312 - medications, and diet shown in the record on 101010 0744. ref SDS 9
091313 - Q063
091315 - ..
091316 - Asked about correlation of peripheral neuropathy parathesia beginning
091317 - OA 13 May 2012, reported in case study on 101010 0744. ref SDS 9 F97O,
091318 - following CABG 4x heart bypass surgery on 091022? ref SDS 3 PQWU
091320 - ..
091321 - Doctor Tseng explained that parathesia can occur in some patients in
091322 - near term of weeks and months after CABG surgery. Therefore, current
091323 - problems of peripheral neuropathy parathesia would not be expected 36
091324 - months after surgery.
091326 - ..
091327 - Hugged Doctor Tseng and thanked her again for good care, reflecting
091328 - last meeting on 091104 0718. ref SDS 5 PR4V
091329 -
091331 - ..
0914 -
0915 -
0916 - 0810
0917 -
091701 - Met with Ramone in Surgery Administration. He called Isagani.
091702 - Isagani told Ramone the customer can meet Isagani at 0900 in Module 2
091703 - of the Clinic on the Ground Floor to discuss letter for Doctor Stewart
091704 - to prepare for meeting at 1330.
091705 -
091706 -
091708 - ..
0918 -
0919 -
0920 - 0900
0921 -
092101 - Met Receptionist in Clinic Module 2. She advised that Isagani is
092102 - still at a staff meeting.
092103 -
092105 - ..
0922 -
0923 -
0924 - 0910
0925 -
092501 - Have to leave for meeting with Trish in ENT on 2nd floor scheduled for
092502 - 0915.
092504 - ..
092505 - Mike was in the customer reception area for Clinic Module 2. He said
092506 - Doctor Stewart's assistant will review the record to prepare for the
092507 - meeting at 1330.
092508 -
092509 - [...below on 130122 1330 at 1540 Jesus advises there wasn't
092510 - enough time for the medical team to review the record to
092511 - prepare for the meeting today. ref SDS 0 W25F
092513 - ..
092514 - Left for meeting with Trish in ENT, reported in another record on
092515 - 130122 0915, ref SDS 20 LS6W
092516 -
092518 - ..
0926 -
0927 -
0928 - 1330
0929 -
092901 - Receptionist said the team has a lot of meetings today scheduled for
092902 - 1330. She said the Doctor's team will call for the patient in 20
092903 - minutes or so.
092904 -
092906 - ..
0930 -
0931 -
0932 - 1340
0933 -
093301 - Nurse called customer for vitals. This was performed and patient
093302 - asked to continue waiting for Doctor Stewart to beging the meeting.
093303 -
093304 -
093306 - ..
0934 -
0935 -
0936 - 1400
0937 -
093701 - Receptionist said meetings are running longer than expected, so the
093702 - meeting scheduled for 1330 has been moved to 1415. She said there is
093703 - enough time for the customer to go outside to a designated area for
093704 - smoking a cigarette, and to go to the cafeteria for an ice cream cone.
093706 - ..
093707 - Walked to the smoking area for a cigarette, and went to the cafeteria
093708 - to the coffee department. They also sell ice cream cones, so ordered
093709 - one to kill more time.
093710 -
093712 - ..
0938 -
0939 -
0940 - 1430
0941 -
094101 - Receptionist advised that new customers get priority over follow up
094102 - customers. Today, the doctor has many new customers so the follow up
094103 - meeting scheduled for 1330 has been further moved 90 minutes to 1500.
094105 - ..
094106 - Asked if there is a library or work area where customers can use a
094107 - notebook computer with online access to the Internet so customers and
094108 - medical providers can work in parallel to increase productivity?
094110 - ..
094111 - The Receptionist pointed to an adjacent door.
094113 - ..
094114 - Walked across the hallway. There is a door marked "Library." There
094115 - was a handwritten note saying the Library is temporarily closed while
094116 - the attendant is away.
094118 - ..
094119 - Asked the receptionist for General Surgery Clinic if there will be
094120 - enough time for follow up customers to leave the building for another
094121 - cigarette and ice cream.
094123 - ..
094124 - The Receptionist indicated that if the customer is called she will
094125 - notify the medical team the customer is on site and temporarily
094126 - stretching their legs, and will return shortly.
094128 - ..
094129 - Offered to leave a cell phone number. The Receptionist said she
094130 - already has the cell number.
094132 - ..
094133 - Walked to the smoking area for Kathy to smoke a cigarette, and went to
094134 - the cafeteria and ordered another ice cream cone to kill more time.
094135 -
094137 - ..
0942 -
0943 -
0944 - 1510
0945 -
094501 - Returned to Clinic Module 2. Receptionist said nobody has called the
094502 - follow up customer yet. She left the station to inquire with the
094503 - medical team.
094505 - ..
094506 - The receptionist returned and advised the follow up customer will be
094507 - called to meet the doctor in 10 minutes.
094509 - ..
094510 - Asked for future meetings if the team can estimate within 30 minutes
094511 - when customers should arrive for scheduled meetings? The customer can
094512 - check in by telephone and plan to arrive at the actual time of the
094513 - meeting, rather than clog the waiting area and hallways?
094515 - ..
094516 - The Receptionist said VA planning has been considering ways to
094517 - increase productivity with both customers and providers working in
094518 - parallel to reduce idle time.
094519 -
094520 -
094521 -
0946 -
094601 -
0947 -
SUBJECTS
Health Care Medical Schedule Meeting 130117 0900 VA Radiology Depart
2503 -
2504 - 1540
250501 - ..
250502 - Met initially with Jesus.
250504 - ..
250505 - Jesus did not have time to review the letter submitted 5 days ago
250506 - enabling the medical team to prepare for the meeting today, reported
250507 - on 130117 0900, ref SDS 19 RX5L, and discussed with Mike earlier this
250508 - morning at 0910, per above, ref SDS 0 02H4, citing planning by Isagani
250509 - to meet this morning at 0900 to review objectives on being prepared
250510 - for a productive meeting.
250512 - ..
250513 - Jesus was able to access the CT files for the barium swallow test at
250514 - the VA in Martinez on 130117 0900. ref SDS 19 HR98
250516 - ..
250517 - He was unable to access Doctor Lee's Progress notes for the EGD
250518 - Dilation procedure at the VA in Sacramenton on 130110 0900.
250519 - ref SDS 18 RG9K
250521 - ..
250522 - Discussed objective and prospects to correct failure of wrap
250523 - constructed to prevent backflow reflux into the esophagus caused by
250524 - Heller Myotomy surgery performed on 091216 0600, ref SDS 6 KE9U, and
250525 - to implement planning at the VA on 091030 0810. ref SDS 4 OY64
250527 - ..
250528 - Since the wrap worked well for 2.5 years, and began failing about 6
250529 - months ago, Doctor Stewart planned to consider in the follow meeting
250530 - today considerations for corrective surgery to accomplish original
250531 - objectives, reported on 121113 1100. ref SDS 14 WB54
250532 -
250533 -
250534 -
250535 -
250536 -
250538 - ..
250539 - Diabetes Not Cause Peripheral Neuropathy Circulation Because Good
250540 - Peripheral Neuropathy Diabetes Not Cause Because Circulation Good
250541 -
250542 - Presented new issue of peripheral neuropathy parathesia, discussed
250543 - with Doctor Elaine Tseng this morning, per above. ref SDS 0 LM8K
250545 - ..
250546 - Jesus indicated that ruling out heart surgery on 091022 as causing
250547 - peripheral neurapathy, another common cause is diabetes. He checked
250548 - patient labs and noted there is no alignment with diabetes. Jesus
250549 - performed then clincial examination of blood flow to lower
250550 - extermeties. He reported finding ample blood flow. Jesus advised
250551 - that patients suffering or susceptible to diabetes symptoms have very
250552 - poor blood flow to their feet.
250554 - ..
250555 - Jesus indicated initial clinical assessment today diagnoses no
250556 - evidence of diabetes causing peripheral neuropathy parathesis. He
250557 - will consult with Doctor Stewart for further consideration.
250558 -
250559 - [On 130227 0930 Doctor Abrams in VA Neurology Department
250560 - concurs patient history and labs do not indicate concern
250561 - about diabetes; orders next lab to include A1c blood test
250562 - for diabetes. ref SDS 23 P44K
250563 -
250564 -
250565 -
2506 -
SUBJECTS
Esophagus Substantial Recovery CT Barrium Swallow Test Compare Prior
3803 -
3804 - 1615
380501 - ..
380502 - Achalasia Recovery CT Imaging Shows Esophagus Substantial Recovery
380503 - Esophagus Substantial Recovery CT Imaging Shows Achalasia Recovery
380504 -
380505 - Doctor Stewart arrives.
380507 - ..
380508 - The doctor initially used the computer monitor in the examination to
380509 - access and review images and medical findings for the CT test with
380510 - barium swallow ordered by Doctor Lee at VA in Sacramento, and
380511 - performed at VA in Martinez on 130117. ref SDS 19 OH6G Doctor Stewart
380512 - then accessed the similar study to assess Heller Myotomy Surgery which
380513 - she performed on 091216, and which was done 2 days later on 091218,
380514 - reported in the record on 100928 0706. ref SDS 8 1357
380516 - ..
380517 - The doctor compared on the same computer monitor a file on the VA
380518 - server in Sacramento with a file on the server located at the VA in
380519 - San Francisco.
380521 - ..
380522 - Displaying the 2 images for tests 3 years apart side-by-side on the
380523 - computer monitor side the doctor said there is significant
380524 - improvement. Doctor Stewart pointed to resolution in the recent study
380525 - of the large bulge in the esophagus above LESV, which previously
380526 - plagued the patient shown in the earlier test 3 years ago on 091218.
380527 - Doctor Stewart further traced on the computer display screen
380528 - elimination of the long string-like narrowing of the esophagus between
380529 - the former big bulge and LESV.
380531 - ..
380532 - Doctor Stewart smiled and said these dramatic changes demonstrate
380533 - success of Heller Myotomy surgery in conjunction with EGD Dilations,
380534 - as listed in the record on 121016 1302. ref SDS 13 XS62
380535 -
380536 - [On 130416 1100 Doctor Lee interpreted CT test on 130117,
380537 - shows remarkable recovery from achalasia; he attributes
380538 - favorable results reflects combination therapy with Heller
380539 - Myotomy surgery performed by Doctor Stewart at VA Medical
380540 - Center in San Francisco on 091216, and subsequent
380541 - persistent EGD dilation protocols every 3 months together
380542 - with Omeprazole medication, and then a year later enhanced
380543 - albeing intermittantly with triamcinolone steriod
380544 - injections to resist contractions of LESV that aid
380545 - swallowing and so avoid ballooning effect of esophagus.
380546 - ref SDS 24 E23K
380548 - ..
380549 - [On 150527 0930 VA Medical Center in San Francisco
380550 - performed another CT Barium Swallow test - preliminary
380551 - results are favorable indicating patient has not suffered
380552 - recurrent achalasia symtom of distorted esophagus, commonly
380553 - called "bird beak," rather esophagus looks normal.
380554 - ref SDS 28 V56N
380556 - ..
380557 - The doctor was unable to access Doctor Lee's Progress Notes on most
380558 - recent EDG Dilation performed a week before the most recent CT study
380559 - for barium swallow test, and on 130110 0900. ref SDS 18 RG9K
380561 - ..
380562 - We reviewed the record of Doctor Lee reporting great news following
380563 - EGD Dilation saying LESV reduced from 18 mm to only 15 mm whereas
380564 - previously LESV had reduced to 9 mm.
380566 - ..
380567 - Doctor Stewart further noted that Doctor Lee's findings together with
380568 - radiology study on 130117, aligns patient records showing dramatic
380569 - reduction in vomitting to clear the esophagus, reported in case study
380570 - on 101010 0744 compare beginning on 101125, ref SDS 9 V34I, with
380571 - recent period on 130110. ref SDS 9 YY7K
380573 - ..
380574 - Improve swallowing directly reflects resolution of esophageal and LESV
380575 - function to near normal, as shown in CT radiology barium swallow study
380576 - on 130117 0900, ref SDS 19 OH6G, and showing...
380577 -
380578 -
380579 - | |
380580 - | |
380581 - | |
380582 - | | Esophagus
380583 - | |
380584 - | |
380585 - | |
380586 - | |
380587 - | |
380588 - | |
380589 - | |
380590 - | |
380591 - \ | Lower Esophageal Spincter Valve (LESV)
380592 - \ \
380593 - / -----------\
380594 - / \
380595 - | \ Stomach
380596 - | |
380597 - | |
380598 - / /
380599 - / ------------ /
380600 - | /
380601 - \ \
380602 - \ --------------
380603 - -- ----------------
380604 -
380606 - ..
380607 - Doctor Stewart's analysis today aligns with conclusion that the EGD
380608 - and Dilation test on 130117 shows esophagus and LESV significantly
380609 - improved, ref SDS 19 OH6G, from the original study on 050714 1000.
380610 - ref SDS 1 6136 There is no big bulge nor long string-like structure
380611 - that was in the original study nearly 8 years ago, 050714 1000,
380612 - ref SDS 1 B94J, and shown again by Doctor Lee in a meeting at the VA
380613 - on 051202 1430. ref SDS 2 5B5K
380614 -
380615 - [On 150527 0930 VA Medical Center in San Francisco
380616 - performed another CT Barium Swallow test - preliminary
380617 - results are favorable indicating patient has not suffered
380618 - recurrent achalasia symtom of distorted esophagus, commonly
380619 - called "bird beak," rather esophagus looks normal.
380620 - ref SDS 28 V56N
380622 - ..
380623 - Recovery from achalasia shows medication need not be increased, and
380624 - that swallowing may continuing improving with reduced Omeprazole
380625 - medication.
380627 - ..
380628 - Doctor Stewart indicated that patient history showing the wrap
380629 - constructed during Heller Myotomy surgery on 091216 worked well for
380630 - over 2 years, and in the past 6 months or so has been failing
380631 - represents an intriguing medical problem.
380633 - ..
380634 - Doctor Stewart noted that correcting the surgical wrap constructed
380635 - with Heller Myotomy surgery on 091216, might resolve reflux when
380636 - laying on left side. There is a risk of worsening current improved
380637 - swallowing achieved at great cost the past 3 years.
380639 - ..
380640 - Therefore until reflux gets worse beyond a mere nusance, prescribed
380641 - care is to avoid resolution at this time.
380642 -
380643 -
380644 -
3807 -
SUBJECTS
Peripheral Neuropathy Parathesia Symptom Feet Numb Tingling Pins Nee
4303 -
430401 - ..
430402 - Spinal Stenosis Possible Diagnosis Peripheral Neuropahy Parathesia
430403 -
430404 - Doctor Stewart asked about patient history of peripheral neuropathy
430405 - parathesia, discussed with Jesus earlier in the meeting, per above.
430406 - ref SDS 0 N56N
430408 - ..
430409 - Reported peripheral neuropathy was presented to the VA in a meeting
430410 - correlating parathesia symptoms with side effects of Rosuvastatin
430411 - medication to manage LDL cholesterol shown in the record on 120514
430412 - 1300, ref SDS 11 6I70, and citing patient history first reported on
430413 - 120422 shown in case study on 101010 0744. ref SDS 9 RQQT, and with
430414 - severe episode on 120513, also in the case study on 101010 0744.
430415 - ref SDS 9 F97O
430417 - ..
430418 - Explained increased hiking seems to correlate with reduced frequency
430419 - and severity for peripheral neuropathy parathesia, reported in another
430420 - meeting at the VA Cardiology on 120906 1100. ref SDS 12 2I4G
430422 - ..
430423 - Peripheral neuropathy parathesia maintained at mild level with further
430424 - increased hiking to 700 miles over the next 3 months, reported in
430425 - another meeting at VA Cardiology on 121206 0900. ref SDS 15 PK5K
430427 - ..
430428 - Explained meeting with Doctor Tseng this morning. She indicated
430429 - peripheral neuropathy parathesia typically occurs, only within weeks
430430 - and at most a few months after surgery, if at all, per agove.
430431 - ref SDS 0 QM4G
430433 - ..
430434 - Doctor Stewart indicated the next most likely cause of parathesia is
430435 - diabetes.
430437 - ..
430438 - The doctor asked if there is numbness below the knees?
430440 - ..
430441 - Explained there is slight tingling like pins and needles and/or
430442 - numbness only in the balls of the feet and toes.
430444 - ..
430445 - The doctor asked if this occurs continuously and when sitting?
430447 - ..
430448 - Explained the problem occurs only occassionaly and never when sitting.
430449 - Usually this problem occurs after starting on a hike. After about .25
430450 - miles, and lasts another .5 to 1 mile, then goes away for rest of 11
430451 - mile hike. A complete daily history of this problem is shown case
430452 - study on 101010 0744, and showing mild occurrance yesterday on 130121.
430453 - ref SDS 9 SM6O
430455 - ..
430456 - Doctor Stewart explained these symptoms correlate with spinal
430457 - stenosis. She will make a referral to the Neurology Department for
430458 - examination and diagnosis.
430459 -
430460 - [On 130203 1541 VA scheduled meeting with Neurology
430461 - Department to evaluate possible diagnosis spinal stenosis,
430462 - and at VA in San Francisco on 130215 1400. ref SDS 21 LM8K
430464 - ..
430465 - [On 130204 0800 May desk clerk at Clinic Module 2 changed
430466 - meeting with Neurology from 130215 1400 to instead 130227
430467 - 0930. ref SDS 22 PR4G
430469 - ..
430470 - [On 130227 0930 Doctor Abrams in VA Neurology Department
430471 - made clinical examination and reported there is no evidence
430472 - of spinal stenosis nor diabetes. ref SDS 23 UT6T
430474 - ..
430475 - This aligns with Doctor Egan's analysis in the recent meeting last
430476 - month on 121206 0900. ref SDS 15 PK5K
430477 -
430478 - [On 131017 1000 doctor explained patient history of
430479 - intermittant and mild peripheral neuropathy that correlates
430480 - with persistent elevated T Bilirubin in lab on 131015,
430481 - ref SDS 25 015M, and further reported with vitals, diet and
430482 - exercise since prior meeting at VA on 130603, see case
430483 - study on 120101 0900, ref SDS 10 X14N, suggests
430484 - intervention is not required at this time to improve
430485 - recovery from side effects taking Rosuvastatin. ref SDS 26
430486 - LV5J
430487 -
430488 -
430489 -
430490 -
430491 -
430492 -
430493 -
430494 -
4305 -