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: April 16, 2013 11:00 AM Tuesday; Rod Welch

VA EGD dilate LESV to 20 mm evaluate Omeprazole.

1...Summary/Objective
2...Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
3...GI Department VA Sacramento Medical Center Administration EGD Dilation
4...Denial of Service Resolved Order Omeprazole Prescription VA Refill System
5...Consent Signed EGD Dilation and Meeting Review Pending Issues
6...Consultation Pending Issues and Sign Consent for EGD Dilation
7...Denial of Service Resolved Order Omeprazole Prescription VA Refill System
8...Swallowing Vomitting Difficulties - Only 4 Events in 6 Months
9...Triamcinoloe Steriod Injection Resumed Prevent LESV Contraction
10...Meeting Doctor Lee Present Results EGD Dilation Procedure
11...Results EGD Dilation Procedure Meeting Doctor Lee Present
12...Progress Notes EGD Dilation Today


..............
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CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
4503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4503 -    ..
4504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
4505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
450501 - Follow up ref SDS B2 0000. ref SDS A9 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
450502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450508 -  ..
4506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4508 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
4509 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
450901 - On 101210 EGD procedure dilated esophageal sphincter valve from 11 to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
450902 - 14 mm.  EGD today dilate from 14 to 17 mm. ref SDS 66 BF6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
450904 -  ..
450905 - Test today was scheduled in VA's letter dated 121107, received on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
450906 - 121112 1527. ref SDS A2 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
450908 -  ..
450909 - On 101216 1021 letter commends medical team for excellent work, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
450910 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
450912 -  ..
450913 - On 110218 0730 4th EGD dilation at VA in Martinez, 110218 0730,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450914 - ref SDS 73 SR8M, and using anesthesia with Fentanyl. ref SDS 73 SR5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
450916 -  ..
450917 - On 110429 0830 5th EGD dilation at VA in Martinez, 110429 1230,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450918 - ref SDS 78 NU8L, and using anesthesia with Fentanyl. ref SDS 78 SR5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
450919 - Good results dilating stricture in LESV to "ring finger," Next EDG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
450920 - dilation ordered in 3 months, on 110729 0730. ref SDS 78 LJ6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
450922 -  ..
450923 - On 110607 1414 visited GI Department, ref SDS 82 HC5H, and Charlene                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
450924 - reported a computer mistakes requires scheduling next EGD dilation on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
450925 - 110819 0830. ref SDS 82 N642  Requested meeting with Doctor Lee, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
450926 - for the purpose of reviewing pending action items. ref SDS 82 4P6J,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
450928 -  ..
450929 - On 110819 0830 EGD and Dilation of stricture at lower esphageal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450930 - sphincter valve. ref SDS 87 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
450932 -  ..
450933 - On 111115 1300 EGD and Dilation structure lowere esphageal sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
450934 - valve (LESV), after 5 months. ref SDS 90 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
450936 -  ..
450937 - On 120322 1030 EGD and Dilation structure lowere esphageal sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
450938 - valve (LESV), after 5 months. ref SDS 93 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
450940 -  ..
450941 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
450942 - VA business unit; reported patient history.  Scheduled EGD and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
450943 - dilation procedure for 1300; returned and performed procedure; dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
450944 - from 9 mm to 18 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
450946 -  ..
450947 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
450948 - improvement recovering from acalasia, LESV contracted only slightly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
450949 - from 18 mm down to 15 mm. ref SDS A9 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450950 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450951 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450952 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450953 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
450955 -  ..
4510 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4511 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4512 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
451301 -  ..
451302 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
451303 - GI Department VA Sacramento Medical Center Administration EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
451304 - 
451305 - Follow up ref SDS A9 NU8L, ref SDS 99 NU8L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
451306 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451307 - Applied pre-proc requirements for NPO after midnight, from letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451308 - 101015 1547. ref SDS 54 4J9L  Last food was at 130109 2210.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
451310 -  ..
451311 - Stayed at Kathy's place last night in Sacremento.  This morning, She                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451312 - drove us to VA Medical Center at Mather AFB.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
451314 -  ..
451315 - Checked into GI Department at the customer counter.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
451316 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451317 -                         800-382-8387                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451318 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451319 -                         916 843 7000                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451320 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451321 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451323 -  ..
451324 - Submitted Kathy's cell phone for designated driver.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
451328 -  ..
451329 - Kathy signed the discharge form affirming she will be designated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
451330 - driver, and responsible to facilitate no driving for 24 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451332 -  ..
451333 - Nurse at customer counter asked questions on patient history to verify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451334 - ready for procedure, e.g., no allergies, and NPO after midnight to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
451335 - avoid conflicts with anesthesia; no health problems, e.g., no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
451336 - diabetes, alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451338 -  ..
451339 - Waited in lobby for 5 minutes.  Then did laps around the building                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
451340 - until called OA 1040.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451341 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451343 -  ..
4514 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4515 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4516 - 0913                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
4517 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
451701 - Denial of Service Resolved Order Omeprazole Prescription VA Refill System                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
451702 - 
451703 - Follow up ref SDS A9 RG9K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
451704 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451705 - There was initial preparation for the procedure dressing down, IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
451706 - setup and administration with patient history, similar to work on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
451707 - 120925 0900. ref SDS 99 UN6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
451708 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451709 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451711 -  ..
451712 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451713 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451714 - Denial of Service Resolved Order Omeprazole Prescription VA Refill System                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
451715 - 
451716 - Follow up ref SDS 99 RG9K, ref SDS 93 SR4G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
451717 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451718 - When Doctor Lee arrived, explained denial of service ordering refills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451719 - for Omeprazole on 130406 1708. ref SDS B3 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451721 -  ..
451722 - Doctor Lee will order Omeprazole refill to resolve the problem.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451724 -  ..
451725 - He indicated that Doctor Sandhu in Primary Care placed a hold for some                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451726 - reason on 3 pending refills.  This explains denial of service reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451727 - on 130406 1708. ref SDS B3 MJ7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451729 -  ..
451730 - Denial of access to VA Internet prescription system is somewhat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451731 - similar to mix up that delayed getting Omeprazole refill reported last                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451732 - year on 120927 1214. ref SDS A0 YK6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
451733 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451734 -            [On 140715 1614 another delay ordering refills for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
451735 -            Omeprazole this time caused by denial of service to VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
451736 -            automatic scheduling that does not align with doctor's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
451737 -            prescription. ref SDS B9 HX5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451739 -  ..
451740 - Today, Doctor Lee cancelled the prior prescription that denied access                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451741 - to refills.  He ordered a new prescription with 3 new refills.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451742 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451743 -            [On 130419 0638 VA Internet medication prescription report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
451744 -            shows Omeprazole ordered 130417 and there are 3 refills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
451745 -            available. ref SDS B5 MJ7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451747 -             ..
451748 -            [On 130423 1140 received refill for Omeprazole. ref SDS B6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451749 -            5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451751 -  ..
451752 - Reviewed results CT test on 130117 0900, ref SDS B0 HR98, showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
451753 - significant improvement reducing swelling. ref SDS B0 OH6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
451755 -  ..
451756 - Reviewed analysis Doctor Stewart finding that CT test on 130117,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
451757 - ordered by Doctor Lee, shows favorable response to treatment resolving                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451758 - achalasia, reported on 130122 1330. ref SDS B1 03H6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
451759 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451760 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451762 -  ..
451763 - Swallowing Vomitting Difficulties - Only 4 Events in 6 Months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451764 - Triamcinoloe Steriod Injection Resumed Prevent LESV Contraction                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
451765 - 
451766 - Follow up ref SDS 99 TZ4M, ref SDS 93 UI9H.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
451767 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451768 - Doctor Lee asked about swallowing and vomitting since the prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451769 - meeting when he resumed triamcinolone steriod injections to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
451770 - contractions of LESV, so that effects of dilation on aiding swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451771 - last longer?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
451773 -  ..
451774 - Reported swallowing has been good, and so vomitting mostly mild during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451775 - past 6 months, since prior procedure on 120925 0900, ref SDS 99 TZ4M,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451776 - when Doctor Lee resumed triamcinolone steriod injections, shown also                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451777 - in Progress Notes on 120925. ref SDS 99 R87N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
451779 -  ..
451780 - Explained Doctor Lee can check daily progress on vomitting since prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451781 - procedure on 120925, by examining the record of patient vitals,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451782 - medication, diet and exercise in case study on the Internet dated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
451783 - 120101 0900, ref SDS 92 UX4H, and showing...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
451784 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451785 -                 20%.................... 120928                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451786 -                  4%.................... 121107                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451787 -                  5%.................... 121128                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451788 -                100%..not achalasia..... 130205 .... norovirus infection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
451789 -                  5%.................... 130314                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451791 -  ..
451792 - Four (4) mild events over 6 months, due to achalasia is remarkable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
451793 - improvement compared to 16 events in prior study without triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451794 - steriod injections, shown on 120925 0900, ref SDS 99 GD8J; and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451795 - compared to 32 events in the next prior study on 120322 1030.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
451796 - ref SDS 93 UI9H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451797 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451798 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451800 -  ..
451801 - Meeting Doctor Lee Present Results EGD Dilation Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
451802 - Results EGD Dilation Procedure Meeting Doctor Lee Present                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
451803 - 
451804 - Follow up ref SDS A9 134H, ref SDS 93 SR6K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
451805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451806 - An hour or so after the procedure, met with Doctor Lee in the recovery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451807 - room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451809 -  ..
451810 - Doctor Lee reported good news...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
451812 -  ..
451813 - LESV remained at 18 mm past 4 months, so next EGD dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451814 - months, October 131001.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
451816 -  ..
451817 - LESV did not contract over past 4 months by any measurable amount.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
451818 - The pneumatic dilation balloon did not engage esophageal tissue until                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451819 - reaching 18 mm, which is the size dilated during the prior meeting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451820 - 130110 0900. ref SDS A9 134H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
451822 -  ..
451823 - Thanked Doctor Lee for outstanding care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
451825 -  ..
451826 - Attributed success reported previously on 130117, and noted that very                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451827 - favorable findings today reflect Doctor Lee's persistance ordering EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451828 - dilation procedures the past 3 years, despite initial poor results,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
451829 - and the doctor's ingenuity adding triamcinolone steriod injections to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451830 - resist contraction of LESV that aids swallowing to prevent swelling of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451831 - esophagus and vomitting, beginning on 110218 0730. ref SDS 73 SR4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
451832 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451833 -                LESV Dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451834 -                Date   from - to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451835 -                130416   18   18.....triamcinolone.... ref SDS 0 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451836 -                130110   15   18.....triamcinolone.... ref SDS A9 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451837 -                120925   15   18.....triamcinolone.... ref SDS 99 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451838 -                120322   16.5 18...................... ref SDS 93 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451839 -                111115   16.5 18...................... ref SDS 90 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451840 -                110819   15   16.5...triamcinolone.... ref SDS 87 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451841 -                110429   13   16.5...triamcinolone.... ref SDS 78 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451842 -                110218   11   14.....triamcinolone.... ref SDS 73 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451843 -                101210   11   14...................... ref SDS 66 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451844 -                100827   11   15...................... ref SDS 49 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451845 -                100305   11   15...................... ref SDS 42 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451847 -  ..
451848 - This record was presented in case study during the meeting with Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451849 - Stewart at San Francisco VA Medical Center on 121016 1302. ref SDS A1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451850 - XS62                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451852 -  ..
451853 - Today, Doctor Lee explained significant improvement swallowing through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451854 - progress resolving acalasia was a team effort.  He advised that Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451855 - Myotomy surgery, which Doctor Stewart performed on 091216 0600,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451856 - ref SDS 31 KE9U, combined with EGD protocols beginning 3 months later                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451857 - on 100305 1000, ref SDS 42 E18F, and then a year later enhanced with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
451858 - triamcinolone steriod injections on 110218 0730, ref SDS 73 SR4G, then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
451859 - paused after 3 cycles on 111115 1300, ref SDS 90 IS6L, but resumed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
451860 - again after 2 more cycles on 120925 0900, ref SDS 99 8S4I, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451861 - continued for the prior cycle on 130110 0900. ref SDS A9 Q34P have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
451862 - finally yielded dramatic results with consistent injections of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451863 - triamcinolone steriods.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
451865 -  ..
451866 - Doctor Lee advised that he applied triamcinolone steriod again today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451867 - to maintain improved swallowing, since this has been effective.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451868 - Progress Notes report pausing triamcinolone steriod for the EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451869 - dilation procedure on 111115 1300, ref SDS 90 IS6L, and was resumed 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
451870 - cycles later, shown by Progress Notes reporting this protocol is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
451871 - effective, on 120925 0900. ref SDS 99 E558                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
451872 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451873 -            [...below on 130416 1100 Progress Note report triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
451874 -            steriod injected into LESV. ref SDS 0 F38G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
451876 -  ..
451877 - Doctor Lee prescribed continuing Omeprazole twice a day for next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
451878 - month, then reducing medication to once a day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451880 -  ..
451881 - Hopefully, this will enable reducing Omeprazole to reduce side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
451882 - effects.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
451883 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451884 -            [...below on 130416 1100 Doctor Lee filed addendum to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
451885 -            Progress Notes prescribing continuing prescription taking 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
451886 -            pills of Omeprazole for only 1 month, then reducing to 1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
451887 -            pill per day for next 5 months until next procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451888 -            ref SDS 0 ZY91                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
451889 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451890 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451891 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451892 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451893 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
451894 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
4519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
4603 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460401 -  ..
460402 - Progress Notes EGD Dilation Today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460403 - 
460404 - Received Progress Notes...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
460405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460406 -              F:\05\00003\SM\CC\AGMJ\20130416122245\welch_050713.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460407 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460408 -    1.  Progress Notes Printed On May 07, 2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460409 -        LOCAL TITLE: EGD 60111                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460410 -        STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460411 -        DATE OF NOTE: APR 16, 2013@12:22                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
460412 -        ENTRY DATE: APR 16, 2013@12:22:45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
460414 -         ..
460415 -    2.  AUTHOR: PARIKH,DHAVAN EXP COSIGNER: LEE,RANDALL E                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
460416 -        URGENCY: STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460417 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460418 -    3.  *** EGD 60111 Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460420 -         ..
460421 -    4.  ESOPHAGOGASTRODUODENOSCOPY REPORT APR 16, 2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460423 -         ..
460424 -    5.  PATIENT NAME; WELCH,RODNEY CHARLES  561-72-0144                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460426 -         ..
460427 -    6.  PREOPERATIVE DIAGNOSIS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
460428 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460429 -        1.  Achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460430 -        2.  Peptic stricture                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460432 -         ..
460433 -    7.  POSTOPERATIVE DIAGNOSIS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460434 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460435 -        1.  Achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460436 -        2.  Peptic stricture s/p TTS balloon dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460438 -         ..
460439 -    8.  SUBPROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460440 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460441 -        1.  TTS balloon dilation of distal esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460442 -        2.  Endoscopic injection of triamcinolone.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460444 -         ..
460445 -    9.  INDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460446 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460449 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460450 -        1.  67-year-old man with a history of achalasia.  He underwent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460451 -            laparoscopic myotomy and fundoplication at San Francisco VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460452 -            Medical Center.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
460453 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460454 -        2.  He subsequently developed acid reflux and a distal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460455 -            esophageal stricture that has required repeat endoscopic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460456 -            dilations.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460458 -             ..
460459 -        3.  His last EGD and dilation was on 01/10/2013, at which time,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460460 -            his stricture was dilated from 15 to 18 mm and 3 mL of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460461 -            triamcinolone acetate with a concentration of 40 mg/mL was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460462 -            injected into the distal esophageal stricture.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
460464 -             ..
460465 -        4.  Patient now returns for repeat dilation.  Generally sx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460466 -            (symptom) free, but has noted a slight increase in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460467 -            dysphagia since his last dilation.  Compliant with Prilosec                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460468 -            20 mg bid.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460470 -         ..
460471 -   10.  PHYSICAL EXAMINATION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
460473 -         ..
460474 -   11.  Vitals - most recent BMI: 31.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460476 -         ..
460477 -   12.  Height: 66 in [167.6 cm] (04/16/2013 10:08)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460478 -        Weight: 193 lb [87.7 kg] (04/16/2013 10:08)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460479 -        Temp: 97.4 F [36.3 C] (04/16/2013 10:08)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460480 -        Pulse: 61 (04/16/2013 10:08)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460481 -        Resp: 16 (04/16/2013 10:08)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460482 -        BP: 132/78 (04/16/2013 10:08)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460484 -         ..
460485 -   13.  GENERAL: awake, alert and cooperative in no acute distress.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460486 -        HEART: RRR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460487 -        LUNGS: CTAB                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460488 -        ABD: BS normal, soft, non-tender.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
460489 -        EXT: No edema.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460490 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460492 -         ..
460493 -   14.  HEALTH STATUS: ASA class 2.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460495 -         ..
460496 -   15.  CONSENT: The procedure was discussed with the patient with the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460497 -        benefits and risks, including but not limited to bleeding,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460498 -        infection, pain, aspiration, perforation and reaction to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460499 -        medications.  Questions were answered.  The patient was aware                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460500 -        of the risks and gave written informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460502 -         ..
460503 -   16.  ENDOSCOPIST: Dr Parikh                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460505 -         ..
460506 -   17.  ATTENDING: Dr Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
460508 -         ..
460509 -   18.  MEDICATIONS: Fentanyl 250 mcg iv, Versed 5 mg iv, Benadryl 50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460510 -        mg iv                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
460512 -         ..
460513 -   19.  TIME IN: 1151                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460514 -        TIME OUT: 1218                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460516 -         ..
460517 -   20.  DESCRIPTION OF PROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
460518 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460519 -        1.  Timeout was performed prior to procedure with name, site,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460520 -            and procedure confirmed.  The procedure was performed in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460521 -            the main endoscopy unit at VA Mather Hospital on an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
460522 -            outpatient basis by Drs Lee and Parikh.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460524 -             ..
460525 -        2.  Incremental doses of fentanyl, versed, and Benadryl were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460526 -            administered for moderate conscious sedation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
460528 -             ..
460529 -        3.  Viscous lidocaine for pharyngeal anesthesia was used and a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460530 -            bite block was inserted in the mouth.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
460532 -             ..
460533 -        4.  The patient was placed in the left lateral decubitus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460534 -            position.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460536 -             ..
460537 -        5.  Vital signs were monitored throughout.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460539 -             ..
460540 -        6.  The Olympus GIF-H180 diagnostic endoscope was directly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460541 -            inserted into the mouth and the esophagus was intubated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460542 -            under direct visualization.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460544 -             ..
460545 -        7.  Retained saliva was observed coating the esophageal mucosa                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460546 -            and this was easily irrigated and suctioned to examine the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460547 -            esophageal mucosa.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460549 -             ..
460550 -        8.  The endoscope was carefully advanced to 40 cm, the site of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460551 -            the known stricture.  The endoscope was easily passed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
460552 -            through and into the stomach without any resistance.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460554 -             ..
460555 -        9.  The endoscope was then advanced into the stomach and to the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460556 -            proximal and descending duodenum.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
460558 -             ..
460559 -            The endoscope was then slowly withdrawn with close                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460560 -            examination of the mucosa.  In the stomach, retroflex view                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460561 -            was obtained.  The endoscope was then straightened.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460562 -            scope was withdrawn to the esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
460564 -             ..
460565 -       10.  At that point a TTS balloon dilator was advanced across the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460566 -            distal esophagus and inflated to 15 mm.  The balloon did                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460567 -            not engage the esophagus at that size, and so the balloon                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460568 -            was further inflated sequentially to 16.5 then 18 mm.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460569 -            balloon was noted to engage the esophageal mucosa at 18 mm,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460570 -            but no tearing was visualized through the balloon.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460571 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460572 -                LESV Dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460573 -                Date   from - to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460574 -                130416   18   18.....triamcinolone.... ref SDS 0 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460575 -                130110   15   18.....triamcinolone.... ref SDS A9 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460576 -                120925   15   18.....triamcinolone.... ref SDS 99 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460577 -                120322   16.5 18...................... ref SDS 93 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460578 -                111115   16.5 18...................... ref SDS 90 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460579 -                110819   15   16.5...triamcinolone.... ref SDS 87 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460580 -                110429   13   16.5...triamcinolone.... ref SDS 78 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460581 -                110218   11   14.....triamcinolone.... ref SDS 73 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460582 -                101210   11   14...................... ref SDS 66 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460583 -                100827   11   15...................... ref SDS 49 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460584 -                100305   11   15...................... ref SDS 42 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460586 -               ..
460587 -              [On 131115 0700 LESV dilated again from 16.5 to 18 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460588 -              indicating minimal contraction with triamcinolone steriod                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460589 -              injections. ref SDS B8 F46N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
460591 -             ..
460592 -       11.  The balloon was then deflated and removed, and two small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460593 -            areas of slight mucosal tearing was appreciated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460595 -             ..
460596 -       12.  Approximately 2 mL of triamcinolone acetate at a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460597 -            concentration of 40 mg/mL were injected into the areas of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460598 -            slight mucosal tearing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460600 -  ..
460601 - Aligns with discussion after the procedure with Doctor Lee, above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460602 - ref SDS 0 I167                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
460604 -  ..
460605 - This continues protocol combining triacinolone steriod with Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460606 - and dilation which has yielded exceptional results, reported today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460607 - above, ref SDS 0 MT6F, and discussed with the doctor after the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
460608 - dilation procedure, also above. ref SDS 0 IN5N  Favorable response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460609 - treatment combining triamcinolone steriod with Omeprazole and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460610 - dilation were previously cited in Progress notes for meetings on...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460611 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460612 -                  130110...................... ref SDS A9 Q374                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460613 -                  120925...................... ref SDS 99 E558                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460614 -                  111115...................... ref SDS 90 AW6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460615 -                  110218...................... ref SDS 73 SR4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460617 -             ..
460618 -            [On 131115 0700 continued protocol injecting triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
460619 -            steriod into LESV to resist contraction that aids                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
460620 -            swallowing and avoid vomitting. ref SDS B7 QS6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
460622 -  ..
460623 - Progress Notes procedure on 130416 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460624 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460625 -       13.  The stomach was then decompressed and the endoscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
460626 -            withdrawn from the esophagus and oropharynx.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
460628 -             ..
460629 -       14.  The patient tolerated the procedure well and there were no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460630 -            immediate complications.  Dr Lee was present for the entire                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460631 -            viewing portion of the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
460633 -         ..
460634 -   21.  FINDINGS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
460635 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460636 -        1.  ESOPHAGUS - proximally dilated and atonic appearing with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460637 -            area of stricture again identified at 40 cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
460639 -             ..
460640 -        2.  GE junction - at 40 cm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460642 -             ..
460643 -        3.  STOMACH - normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
460645 -             ..
460646 -        4.  DUODENUM - normal to D2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460648 -             ..
460649 -        5.  RETROFLEX - anatomy c/w prior fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
460651 -         ..
460652 -   22.  IMPRESSION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460653 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460654 -        1.  Atonic and proximally dilated esophagus with area of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460655 -            stricture at 40 cm, easily traversed by endoscope without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460656 -            resistance.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
460658 -             ..
460659 -        2.  Status post attempted dilation of previous stricture at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460660 -            40 cm with very slight augmentation in esophageal diameter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460661 -            as noted with two small mucosal tears, s/p 2 mL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
460662 -            triamcinolone (40 mg/mL) injection 3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
460664 -             ..
460665 -        3.  Anatomy consistent with previous fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
460667 -         ..
460668 -   23.  RECOMMENDATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
460669 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460670 -        1.  Continue Omeprazole 20 mg twice daily.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460671 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460672 -        2.  Chew food carefully.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460673 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460674 -        3.  GERD-related lifestyle modifications                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460676 -             ..
460677 -        4.  Repeat EGD and dilation in approximately 6 months, or when                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460678 -            sx return                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460679 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460680 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460681 -   24.  /es/ Dhavan Parikh MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
460682 -        Gastroenterology Fellow, PGY-5 & ED Attending                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
460683 -        Signed: 04/16/2013 13:10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460684 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460685 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460686 -   25.  /es/ RANDALL E LEE, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460687 -        STAFF PHYSICIAN, GASTROENTEROLOGY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
460688 -        Cosigned: 04/16/2013 13:31                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460689 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460690 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460691 -   26.  04/16/2013 ADDENDUM STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
460692 -        Gastroenterology Attending                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
460694 -         ..
460695 -   27.  EGD, TTS dilation, triamcinolone injection performed with Dr                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
460696 -        Parikh as documented above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460698 -         ..
460699 -   28.  GERD stricture is essentially unchanged from last examination                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460700 -        with persistence of lumen diameter at 18mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
460702 -         ..
460703 -   29.  I concur with the above documentation with the following                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460704 -        changes:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460706 -         ..
460707 -   30.  I asked Mr  Welch to continue with omeprazole 20mg twice daily                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
460708 -        x 1 month, then reduce to 20mg once every evening just before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460709 -        dinner.  This is in accordance with his request.  Will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460710 -        recommend continued twice daily dosing if lumen is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
460711 -        significantly reduced at next EGD in October 2013.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
460713 -  ..
460714 - This aligns with objectives for reducing reliance on medication,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
460715 - discussed with the doctor based on good news of significant recovery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
460716 - from achalasia, per above. ref SDS 0 CO5N,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
460717 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460718 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460719 -   31.  /es/ RANDALL E LEE, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
460720 -        STAFF PHYSICIAN, GASTROENTEROLOGY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
460721 -        Signed: 04/16/2013 13:40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460722 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460723 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460724 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460725 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460726 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460727 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460728 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460729 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460730 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460731 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460732 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
460733 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
4608 -