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 -