THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: November 15, 2013 07:00 AM Friday; Rod Welch

VA EGD dilate LESV to 20 mm evaluate Omeprazole.

1...Summary/Objective
2...Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
3...GI Department VA Sacramento Medical Center Administration EGD Dilation
4...Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
5...Consent Signed EGD Dilation and Meeting Review Pending Issues
6...Consultation Pending Issues and Sign Consent for EGD Dilation
7...Swallowing Vomitting Difficulties Decreased with Triamcinolone Injections
8...Dilated 18 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee
9...Meeting Doctor Lee Present Results EGD Dilation Procedure
10...Results EGD Dilation Procedure Meeting Doctor Lee Present
11...Progress Notes EGD Dilation Today
12...Biopsy Report Progress Notes EGD Dilation
13...Progress Notes EGD Dilation Biopsy Report
14...Discharge Instructions Blank No Signature No Date
15...Letter Doctor Summary Results EGD Dilation Biopsy

ACTION ITEMS.................. Click here to comment!

1...This part of the medical chart varies somewhat from Discharge form

CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 16.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
5103 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
5103 -    ..
5104 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
5105 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
510501 - Follow up ref SDS B4 0000. ref SDS B2 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
510502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510504 -            [On 131121 1604 ordered refill of Omeprazole to aid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
510505 -            digestion.  There is 1 refill remaining. ref SDS B8 YS4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
510507 -             ..
510508 -            [On 131205 1443 received order for Omeprazole prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
510509 -            placed on 131121. ref SDS B9 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
510511 -             ..
510512 -            [On 140318 1043 received letter cancelling meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
510513 -            scheduled for EGD/Dilation procedure on 140425 1000,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510514 -            ref SDS C0 935L; a second letter scheduled prodedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
510515 -            140509 0900. ref SDS C0 5D7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
510516 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510517 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510518 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510521 -  ..
5106 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
5107 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
5108 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
5109 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
510901 - On 101210 EGD procedure dilated esophageal sphincter valve from 11 to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
510902 - 14 mm.  EGD today dilate from 14 to 17 mm. ref SDS 66 BF6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
510904 -  ..
510905 - Test today was scheduled in VA's letter dated 121107, received on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
510906 - 121112 1527. ref SDS A2 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
510908 -  ..
510909 - On 101216 1021 letter commends medical team for excellent work, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
510910 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
510912 -  ..
510913 - On 110218 0730 4th EGD dilation at VA in Martinez, 110218 0730,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510914 - ref SDS 73 SR8M, and using anesthesia with Fentanyl. ref SDS 73 SR5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
510916 -  ..
510917 - On 110429 0830 5th EGD dilation at VA in Martinez, 110429 1230,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510918 - ref SDS 78 NU8L, and using anesthesia with Fentanyl. ref SDS 78 SR5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
510919 - Good results dilating stricture in LESV to "ring finger," Next EDG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
510920 - dilation ordered in 3 months, on 110729 0730. ref SDS 78 LJ6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
510922 -  ..
510923 - On 110607 1414 visited GI Department, ref SDS 82 HC5H, and Charlene                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
510924 - reported a computer mistakes requires scheduling next EGD dilation on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
510925 - 110819 0830. ref SDS 82 N642  Requested meeting with Doctor Lee, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
510926 - for the purpose of reviewing pending action items. ref SDS 82 4P6J,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
510928 -  ..
510929 - 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
510930 - valve. ref SDS 87 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
510931 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510932 - 111115 1300 EGD and Dilation structure lowere esphageal sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
510933 - valve (LESV), after 5 months. ref SDS 90 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
510934 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510935 - 120322 1030 EGD and Dilation structure lowere esphageal sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
510936 - valve (LESV), after 5 months. ref SDS 92 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
510937 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510938 - 120925 0900 meeting Doctor Lee reported schedule mistake using new VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
510939 - business unit; reported patient history.  Scheduled EGD and dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
510940 - procedure for 1300; returned and performed procedure; dilated from 9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
510941 - mm to 18 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
510943 -  ..
510944 - 130110 0900 meeting Doctor Lee EGD procedure found improvement                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
510945 - recovering from acalasia, LESV contracted only slightly from 18 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
510946 - down to 15 mm. ref SDS A9 134H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
510948 -  ..
510949 - 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
510950 - remained at 18 MM, ref SDS B4 6P6G, same as dialated 4 months earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
510951 - on 130110 0900. ref SDS A9 134H  Doctor Lee injected steriod again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
510952 - maintain swallowing. ref SDS B4 I167  Prescribed reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
510953 - to 1 pill per day. ref SDS B4 R74M  Scheduled next EDG dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
510954 - months, instead of 3. ref SDS B4 6P6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
510955 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510956 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510957 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510958 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510959 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
510961 -  ..
5110 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
5111 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
5112 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
511301 -  ..
511302 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
511303 - GI Department VA Sacramento Medical Center Administration EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
511304 - 
511305 - Follow up ref SDS B4 NU8L, ref SDS B2 NU8L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
511306 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511307 - Applied pre-proc requirements for NPO after midnight, from letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
511308 - 101015 1547. ref SDS 54 4J9L  Last food was at 131114 1722.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
511310 -  ..
511311 - Stayed at Kathy's place last night in Sacremento.  This morning, She                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
511312 - drove us to VA Medical Center at Mather AFB.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
511314 -  ..
511315 - Checked into GI Department at the customer counter.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
511316 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511317 -                         800-382-8387                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
511318 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511319 -                         916 843 7000                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
511320 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511321 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511323 -  ..
511324 - Submitted Kathy's cell phone for designated driver.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
511328 -  ..
511329 - Kathy signed the discharge form affirming she will be designated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
511330 - driver, and responsible to facilitate no driving for 24 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
511332 -  ..
511333 - Nurse at customer counter asked questions on patient history to verify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
511334 - ready for procedure, e.g., no allergies, and NPO after midnight to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
511335 - avoid conflicts with anesthesia; no health problems, e.g., no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
511336 - diabetes, alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
511338 -  ..
511339 - Waited in lobby for 5 minutes.  Then did laps around the building                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
511340 - until called OA 1040.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
511341 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511343 -  ..
5114 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
5115 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
5116 - 0748                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
5117 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
511701 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
511702 - 
511703 - Follow up ref SDS B4 ZG3F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
511704 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511705 - There was initial preparation for the procedure dressing down, IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
511706 - setup and administration with patient history, similar to work on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
511707 - 120925 0900. ref SDS 99 UN6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
511708 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511709 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511710 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511712 -  ..
511713 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
511714 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
511715 - 
511716 - Follow up ref SDS B4 RG9K, ref SDS 99 RG9K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
511717 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511718 - Doctor Lee came into the surgery preparation room smiling and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
511719 - immediately shook hands on mutually having hiked Half Dome, saying he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
511720 - did Half Dome about 20 years ago.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
511722 -  ..
511723 - The doctor related seeing Doctor Egan's Progress Notes for meeting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
511724 - 131017, which reporting Half Dome Hike was challenging for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
511725 - patient, but successful. ref SDS B7 V24N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
511727 -  ..
511728 - Doctors preparing for meetings by reading up on the record of recent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
511729 - related work shows good progress toward doctor/patient partnership                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
511730 - that leverages talents and experience essential for effective,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
511731 - comprehensive health care, discussed previously on 120925 0900.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511732 - ref SDS 99 UI3F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
511734 -  ..
511735 - Doctor Lee mentioned that he wants to hike Half Dome again with his 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
511736 - oldest children They enjoy hiking now in their early teens, and are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
511737 - growing fast.  He expects that within a year or so they will try Half                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
511738 - Dome together.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
511739 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511740 -            [On 140509 0900 at 1040 Doctor Lee requested pictures of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
511741 -            Half Dome hike last year, ref SDS C1 ZZ6J, and explains to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
511742 -            nursing staff how he saved patients life 5 years earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
511743 -            making referral that led to timely heart surgery,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
511744 -            ref SDS C1 0N6I; later in the OR arranged for Doctor Lee to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
511745 -            see pictures hiking Half Dome in Yosemite Valley, and prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
511746 -            to commencement of GI dilation procedure. ref SDS C1 LX7L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
511748 -  ..
511749 - Advised Doctor Lee there is no need to order Omeprazole refill,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511750 - because this was done on 130416 1100. ref SDS B4 RG9K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
511752 -  ..
511753 - On 130419 0638 VA Internet medication prescription report shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511754 - Omeprazole ordered 130417 and there are 2 refills available.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
511755 - ref SDS B5 MJ7M  On 130423 1140 received refill for Omeprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
511756 - ref SDS B6 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
511757 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511758 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511759 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511761 -  ..
511762 - Swallowing Vomitting Difficulties Decreased with Triamcinolone Injections                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
511763 - 
511764 - Follow up ref SDS B4 QW7L, ref SDS A9 SE7K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
511765 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511766 - Doctor Lee asked about swallowing over the prior 6 months, since the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
511767 - prior EDG dilation on 130416 1100. ref SDS B4 QW7L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
511769 -  ..
511770 - Advised swallowing remains good since triamciolone injections resumed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
511771 - on 120925 0900. ref SDS 99 TZ4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
511773 -  ..
511774 - In the past month there has begun to be slight build up in esohpagus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
511775 - (throat) a few times when eating, and which has caused slight                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
511776 - vomitting.  This remains significantly improved compared to prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
511777 - severe swallowing and vomitting problems reported on 120925 0900,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
511778 - ref SDS 99 TZ4M, and previously on 120322 1030. ref SDS 92 UI9H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
511779 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511780 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511781 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511782 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
511784 -  ..
5118 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
5119 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
5120 - 1000                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
5121 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
512101 - Dilated 18 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
512102 - Meeting Doctor Lee Present Results EGD Dilation Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
512103 - Results EGD Dilation Procedure Meeting Doctor Lee Present                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
512104 - 
512105 - Follow up ref SDS B4 5R4N. ref SDS 99 SR6K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
512106 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512107 - An hour or so after the procedure, met with Doctor Lee in the recovery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
512108 - room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
512110 -  ..
512111 - Doctor Lee reported good news...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
512113 -  ..
512114 - LESV contracted to only 16.5 mm past 6 months.  Dilation was performed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
512115 - back to 18 mm.  Next EGD dilation was continued for 6 months, April                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
512116 - 140501.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
512117 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512118 -            [...below on 131115 0700 medical chart Progress Notes may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
512119 -            indicate LESV contracted to 16.5 mm and was dilated to 18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
512120 -            mm. ref SDS 0 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
512121 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512122 -                LESV Dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512123 -                Date   from - to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512124 -                131115   16.5 18.....triamcinolone.... ref SDS 0 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
512125 -                130416   18   18.....triamcinolone.... ref SDS B4 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512126 -                130110   15   18.....triamcinolone.... ref SDS A9 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512127 -                120925   15   18.....triamcinolone.... ref SDS 99 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512128 -                120322   16.5 18...................... ref SDS 92 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512129 -                111115   16.5 18...................... ref SDS 90 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512130 -                110819   15   16.5...triamcinolone.... ref SDS 87 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512131 -                110429   13   16.5...triamcinolone.... ref SDS 78 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512132 -                110218   11   14.....triamcinolone.... ref SDS 73 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512133 -                101210   11   14...................... ref SDS 66 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512134 -                100827   11   15...................... ref SDS 49 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
512135 -                100305   11   15...................... ref SDS 42 WR6L
512136 -  ..
512137 - Doctor Lee advised that he applied triamcinolone steriod again today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
512138 - to maintain improved swallowing, since this has been effective.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512139 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512140 -            [...below on 131115 0700 medical chart Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
512141 -            report injecting trimacinolone steriod. ref SDS 0 V35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
512143 -  ..
512144 - Doctor Lee prescribed continuing Omeprazole once a day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
512146 -  ..
512147 - Kathy understood the doctor ordered the same prescription of starting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
512148 - with 2 pills a day, for a month, then reducing to 1 pill per day, as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
512149 - prescribed previouly on 130416 1100. ref SDS B4 R74M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
512150 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512151 -            [...below on 131115 0700 medical chart Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
512152 -            report doctor ordered taking 2 pills for a month, then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
512153 -            reducing back to 1 pill per day. ref SDS 0 ZY5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
512155 -  ..
512156 - Explained there are 2 refills remaining on the current prescription,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
512157 - reported on 130419 0638. ref SDS B5 MJ7M  This is sufficient to last                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
512158 - another 6 months, so there is no need for Doctor Lee to file another                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
512159 - order.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
512160 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512161 -            [On 131121 1604 ordered refill of Omeprazole to aid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
512162 -            digestion.  There is 1 refill remaining. ref SDS B8 YS4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
512164 -             ..
512165 -            [On 131205 1443 received order for Omeprazole prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
512166 -            placed on 131121. ref SDS B9 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
512168 -  ..
512169 - Kathy further recalled Doctor Lee saying he observed during EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512170 - procedure some new scar tissue around the LESV stricture caused by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
512171 - acid reflux.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
512173 -  ..
512174 - Doctor Lee advised that he took 3 or 4 biopsies during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
512175 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512176 -            [...below on 131115 0700 medical chart Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
512177 -            findings 2,3,5 indicate where biopsies taken to evaluate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
512178 -            tissue condition caused by achalasia. ref SDS 0 UP7F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512180 -  ..
512181 - Results will be reported in the medical chart with Progress Notes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
512182 - probably available next week OA 131120.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
512183 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512184 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512185 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
512186 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
5122 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Medical Chart Progress Notes VA EGD Procedure Stricture Lower Esopha                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
6303 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
630401 -  ..
630402 - Progress Notes EGD Dilation Today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630403 - 
630404 - Follow up ref SDS B4 CY7I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
630405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630406 - Received Progress Notes...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
630407 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630408 -              F:\05\00003\SM\CC\AGMJ\20131115-080024\Welch_11-22-13.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630410 -         ..
630411 -    1.  Progress Notes Printed On 22 November 2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630412 -        LOCAL TITLE: EGD 60111                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
630413 -        STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630414 -        DATE OF NOTE: NOV 15, 2013@08:00                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
630415 -        ENTRY DATE: NOV 15, 2013@14:03:24                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
630417 -         ..
630418 -    2.  AUTHOR: LEE,RANDALL E                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
630419 -        URGENCY: STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630420 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630421 -    3.  *** EGD 60111 Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630422 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630423 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630428 -         ..
630429 -    4.  NAME OF PROCEDURES:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
630430 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630431 -        1.  ESOPHAGOGASTRODUODENOSCOPY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630432 -        2.  Endoscopic biopsy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
630433 -        3.  TTS balloon dilation of his esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630434 -        4.  Endoscopic injection of triamcinolone.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630436 -         ..
630437 -    5.  ATTENDING PHYSICIAN:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
630438 -        Randall E Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
630440 -         ..
630441 -    6.  PREOPERATIVE DIAGNOSIS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
630442 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630443 -        1.  Achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630444 -        2.  Peptic stricture                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
630446 -         ..
630447 -    7.  POSTOPERATIVE DIAGNOSIS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630448 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630449 -        1.  Achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630450 -        2.  Peptic stricture s/p TTS balloon dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630452 -         ..
630453 -    8.  INDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630454 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630457 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630458 -        1.  ...is a 67-year-old man with a history of achalasia.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630459 -            underwent laparoscopic myotomy and fundoplication at San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630460 -            Francisco VA Medical Center, but then developed acid reflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630461 -            and a distal esophageal stricture that has required repeat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630462 -            endoscopic dilations.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
630464 -             ..
630465 -        2.  His last EGD and dilation was on April 2013, at which time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630466 -            he had only mild mucosal trauma after inflation of a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630467 -            balloon to 18 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
630469 -             ..
630470 -        3.  Triamcinolone acetate was injected into the stricture.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630472 -             ..
630473 -        4.  He was maintained on Omeprazole initially at 20 mg twice                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630474 -            daily for 1 month then dropped down to maintenance therapy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630475 -            at 20 mg once daily.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630477 -             ..
630478 -        5.  He is now here for reevaluation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
630480 -             ..
630481 -        6.  In the Interim, he noted that his swallowing ability was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630482 -            consistently maintained until about the last month when he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630483 -            began noticing some dysphagia primarily to meet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
630485 -             ..
630486 -        7.  He has a co-diagnosis of coronary artery disease and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630487 -            successfully underwent a coronary artery bypass and graft.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630489 -             ..
630490 -        8.  Earlier this year he succesfully climbed to the top of Half                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630491 -            Dome in Yosemite National Park.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
630493 -         ..
630494 -    9.  CONSENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
630495 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630496 -        The risks, benefits, and alternatives to this procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
630497 -        including but not limited to the risks of bleeding and bowel                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630498 -        perforation were explained to the patient.  The patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
630499 -        understood and provided written informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
630501 -         ..
630502 -   10.  INTRAVENOUS MEDICATIONS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
630503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630504 -        1.  Diphenhydramine 50 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630505 -        2.  Fentanyl 200 mcg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
630506 -        3.  Midazolam 4 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
630508 -         ..
630509 -   11.  PROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630510 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630511 -        1.  In the Sacramento VA GI Endoscopy Unit, the patient was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630512 -            placed in the left lateral decubitus position.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
630514 -             ..
630515 -        2.  Oxygen at 2 liters per minute by nasal cannula was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
630516 -            administered.  Continuous oximetric and hemodynamic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
630517 -            monitoring was initiated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630519 -             ..
630520 -        3.  Intravenous sedation was administered in divided doses.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630522 -             ..
630523 -        4.  After a bite block was placed in the patient's mouth, an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630524 -            Olympus GIFH180J videogastroscope was advanced under direct                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630525 -            vision into the esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630527 -             ..
630528 -        5.  A small amount of retained saliva within the esophagus was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630529 -            easily irrigated and suctioned away.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630531 -             ..
630532 -        6.  At approximately 39 cm, there was an esophageal narrowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630533 -            with a small associated erosion, which did not impede                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
630534 -            passage of the diagnostic endoscope.  Endoscope was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
630535 -            advanced into the descending duodenum.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630537 -             ..
630538 -        7.  Retroflexed views of incisura, fundus, and cardia were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630539 -            performed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630541 -             ..
630542 -        8.  Random biopsies were taken from the antrum labeled A, from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630543 -            the gastric body, from the GE junction at 39 cm labeled C.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630545 -             ..
630546 -        9.  A TTS balloon dilator was advanced across the distal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630547 -            esophagus and inflated sequentially to 15, 16.5, and then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630548 -            18 mm.  As visualized through the balloon, some small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
630549 -            amount of mucosal tearing was noted at 18 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
630551 -  ..
630552 - This record is not clear whether the balloon engaged LESV anywhere                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630553 - between 15-18mm, as reported for the prior procedure on 130416 1100.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630554 - ref SDS B4 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630556 -  ..
630557 - After the procedure, the doctor seemed to say LESV contracted back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630558 - 16.5 mm, ref SDS 0 CO5N, but this is not expressly stated in Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630559 - Notes. ref SDS 0 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630560 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630561 -                LESV Dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
630562 -                Date   from - to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630563 -                131115   16.5 18.....triamcinolone..2.0mL.... ref SDS 0 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
630564 -                130416   18   18.....triamcinolone..2.0mL.... ref SDS B4 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630565 -                130110   15   18.....triamcinolone..3.0mL.... ref SDS A9 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630566 -                120925   15   18.....triamcinolone..4.0mL.... ref SDS 99 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630567 -                120322   16.5 18............................. ref SDS 92 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630568 -                111115   16.5 18............................. ref SDS 90 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630569 -                110819   15   16.5...triamcinolone..2.5mL.... ref SDS 87 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630570 -                110429   13   16.5...triamcinolone..3.5mL.... ref SDS 78 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630571 -                110218   11   14.....triamcinolone..2.0mL.... ref SDS 73 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630572 -                101210   11   14............................. ref SDS 66 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630573 -                100827   11   15............................. ref SDS 49 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630574 -                100305   11   15............................. ref SDS 42 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630576 -             ..
630577 -            [On 140509 0900 Progress Notes are silent on triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
630578 -            steriod injection - nothing is said except "...a small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630579 -            amount of mucosal tearing" occurred dilating LESV,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
630580 -            ref SDS C1 P680, which appears conflicting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
630581 -            understandings from post-procedure discussion with the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630582 -            doctor seeming to indicate that triamcinolone injection was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630583 -            not done because there was no tearing. ref SDS C1 O36G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
630585 -  ..
630586 - Progress Notes for EGD Dilation procedure on 131115 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630587 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630588 -       10.  The balloon was deflated, removed, and 2 mm of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
630589 -            triamcinolone acetate at a concentration of 40 mg/mL were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630590 -            injected into the areas of mucosal tearing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630592 -  ..
630593 - Continues prior protocol reported on 130416 1100. ref SDS B4 F38G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
630594 - Aligns with discussion following meeting with the Doctor after the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630595 - procedure, shown above. ref SDS 0 I167                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630597 -  ..
630598 - Progress Notes for EGD Dilation procedure on 131115 continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630599 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630600 -       11.  The stomach was decompressed and the gastroscope removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630602 -             ..
630603 -       12.  Complications none.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
630605 -         ..
630606 -   12.  FINDINGS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
630607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630608 -        1.  Previous area of esophageal stricture again identified as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630609 -            measured at 39 cm.  This is coincident with the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
630610 -            gastroesophageal junction.  Initial estimation of starting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630611 -            diameter is 16.5 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630613 -  ..
630614 - Aligns with understandings meeting with the doctor, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
630615 - ref SDS 0 CO5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
630617 -             ..
630618 -        2.  As visualized under narrow band imaging, a suggestion of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630619 -            columnar appearing mucosa immediately at the GE junction.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630620 -            This was biopsied, labeled specimen C.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630622 -  ..
630623 - Photographs taken during EGD procedure are stored in the record at...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630624 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630625 -              F:\05\00003\SM\CC\AGMJ\20131115-080024\Welch_11-22-13-photograph.docx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630627 -             ..
630628 -        3.  Shallow erosion in the squamous mucosa immediately above                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630629 -            the esophageal stenosis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630631 -             ..
630632 -        4.  Gastric fundus surgically altered consistent with known                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630633 -            history of fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630635 -             ..
630636 -        5.  Gastric antrum mucosa appears pale with a clear                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
630637 -            demarcation line.  This was biopsied, labeled specimen A.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630639 -             ..
630640 -        6.  Normal pylorus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
630642 -             ..
630643 -        7.  Normal duodenum to D2.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630645 -         ..
630646 -   13.  IMPRESSION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630647 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630648 -        1.  Gastroesophageal reflux stricture with minor recurrence on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630649 -            prior examination and dilation of April 2013.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
630651 -  ..
630652 - Citing procedure on 130416 1100. ref SDS B4 ZY41                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630653 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630654 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630655 -        2.  Atonic esophageal body with collection of saliva consistent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630656 -            with known diagnosis of achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
630658 -             ..
630659 -        3.  Fundoplication remains intact.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
630661 -  ..
630662 - See photograph...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630663 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630664 -              F:\05\00003\SM\CC\AGMJ\20131115-080024\Welch_11-22-13-photograph.docx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630665 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630666 -               [On 140509 0900 Progress Notes for follow up EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630667 -               Dilation report Appearance of hiatal hernia suggests the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630668 -               fundoplication appears to be loosening. ref SDS C2 I93F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
630670 -                ..
630671 -               [On 141107,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
630673 -                ..
630674 -               [On 150319 0800 meeting with Doctor Lee indicated acid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
630675 -               reflux increased causing ulceration and constriction to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630676 -               LESV that hampers swallowing, because fundoplication has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630677 -               unraveled, i.e., failed, ref SDS C3 N535; remedy -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630678 -               referral to Doctor Stewart to assess re-fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630679 -               or other measures. ref SDS C3 JQ5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630681 -             ..
630682 -        4.  Gastritis within the antrum without evidence of malignancy,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
630683 -            erosion or ulceration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630684 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630686 -         ..
630687 -   14.  RECOMMENDATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
630688 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630689 -        1.  Increase Omeprazole to 20 mg twice daily times 1 month,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630690 -            then reduce back down to maintenance dosage of 20 mg once                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630691 -            daily.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630692 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630693 -               [On 131121 1604 ordered refill of Omeprazole to aid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630694 -               digestion.  There is 1 refill remaining. ref SDS B8 YS4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
630696 -                ..
630697 -               [On 131205 1443 received order for Omeprazole prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
630698 -               placed on 131121. ref SDS B9 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630700 -             ..
630701 -        2.  Repeat EGD and dilation in approximately 6 months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
630702 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630703 -               [On 140318 1043 received letter cancelling meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630704 -               scheduled for EGD/Dilation procedure on 140425 1000,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630705 -               ref SDS C0 935L; a second letter scheduled prodedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
630706 -               140509 0900. ref SDS C0 5D7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
630708 -             ..
630709 -        3.  Await pathology results.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630710 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630712 -         ..
630713 -        DISPOSITION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
630714 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630715 -        1.  The patient was observed in the Recovery Room then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
630716 -            discharged to home with companion.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
630717 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630718 -        2.  I reviewed the endoscopic findings with the patient prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
630719 -            to discharge.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
630721 -         ..
630722 -   15.  TIME START:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630723 -        0847 hours                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
630725 -         ..
630726 -        TIME END:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
630727 -        0909 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
630729 -         ..
630730 -   16.  D:  11/15/2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630731 -        T:  11/15/2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
630732 -        Job number:  1192432                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
630733 -        JLO/CMTS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630734 -        $end:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
630735 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630736 -   17.  /es/ RANDALL E LEE, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
630737 -        STAFF PHYSICIAN, GASTROENTEROLOGY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
630738 -        Signed: 11/20/2013 08:49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630739 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
630740 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
6308 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
VA EDG Biopsy Stomach Chronic Gastritis No Evidence Helicobacter Pyl                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
7803 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
780401 -  ..
780402 - Biopsy Report Progress Notes EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
780403 - Progress Notes EGD Dilation Biopsy Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
780404 - 
780405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780406 -   18.  11/20/2013 ADDENDUM STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
780407 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780408 -        Microscopic exam/diagnosis: (Date Spec taken: Nov 15, 2013)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
780409 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780410 -        A.  STOMACH, ANTRUM (BIOPSY):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
780411 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780412 -            - CHRONIC GASTRITIS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
780413 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780414 -            - NO EVIDENCE OF HELICOBACTER PYLORI BY WARTHIN STARRY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
780415 -              STAIN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
780417 -             ..
780418 -        B.  STOMACH, BODY (BIOPSY): CHRONIC GASTRITIS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
780420 -             ..
780421 -        C.  GASTROESOPHAGEAL JUNCTION, 39CM (BIOPSY):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
780422 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780423 -            - SQUAMOCOLUMNAR MUCOSA WITH ACUTE AND CHRONIC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
780424 -              INFLAMMATION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
780425 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780426 -            - NEGATIVE FOR INTESTINAL METAPLASIA (BARRETT'S                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
780427 -              ESOPHAGUS)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
780428 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780430 -         ..
780431 -   19.  In Reply Refer to:  Sacramento VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
780432 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780433 -        Gastroenterology (111G/SMAT)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
780434 -        Mr. Rodney C Welch                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
780435 -        1158 St Matthew Place                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
780436 -        Unit 103                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780437 -        Concord CA 94518                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
780438 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780439 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780440 -  *******************************************                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
780441 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780442 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
780443 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
7805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Letter VA Doctor Summary Results EGD Dilation Biopsy Medical Chart P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
9303 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930401 -         ..
930402 -    1.  LOCAL TITLE: Pre-Procedure Note 60302                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930403 -        STANDARD TITLE: PROCEDURE NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930404 -        DATE OF NOTE: NOV 15, 2013@08:00 ENTRY DATE: NOV 15, 2013@08:28:47                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930405 -        AUTHOR: LEE,RANDALL E EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930406 -        URGENCY: STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930407 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930408 -        *** Pre-Procedure Note 60302 Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930410 -         ..
930411 -        DATE AND TIME OF PROCEDURE: Nov 15,2013@08:00                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930413 -         ..
930414 -    2.  CONSENT (select ONE option): I-Med note by procedure prov                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930416 -         ..
930417 -    3.  PROCEDURE: egd dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930419 -         ..
930420 -    4.  PROVIDER: rlee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930422 -         ..
930423 -    5.  INDICATION: esophageal stenosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930425 -         ..
930426 -    6.  ALLERGIES: Reviewed; CPRS up to date                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930428 -         ..
930429 -    7.  SITE: egd                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930431 -         ..
930432 -    8.  SIDE: N/A                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930434 -         ..
930435 -    9.  CHECKLIST ITEMS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930436 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930437 -        1.  Name confirmed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930438 -        2.  DOB confirmed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930439 -        3.  SSN confirmed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930440 -        4.  MD/Pt confirmed procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930441 -        5.  All equipment good to go                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930442 -        6.  All staff in agreement                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930444 -         ..
930445 -   10.  CHECKLIST STATUS: Items 1-6 have been confirmed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930446 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930448 -         ..
930449 -   11.  CONSCIOUS SEDATION PRE-PROCEDURE NOTE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930450 -        ASA Level: 2.0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930452 -         ..
930453 -   12.  MD/DENTIST/NP ASSESSMENT:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930454 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930455 -        1.  PATIENT HISTORY:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930456 -              NEURO:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930457 -                Stroke/Encephalopathy: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930458 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930459 -              AIRWAY:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930460 -                Prior problems with intubation: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930461 -                Recent stridor/snoring: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930463 -               ..
930464 -              RESP:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930465 -                Chronic Bronchitis/Emphysema/Asthma: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930466 -                No history of OSA.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930468 -               ..
930469 -              INFECTIOUS DISEASE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930470 -                AIDS/Hepatitis: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930472 -               ..
930473 -              GI/GU:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930474 -                Kidney Disease: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930475 -                Liver Disease: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930477 -               ..
930478 -              ENDOCRINE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930479 -                Diabetes? No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930481 -               ..
930482 -              CV:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930483 -                HTN: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930484 -                MI/Angina: CABG; asymptomatic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930485 -                CHF: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930486 -                AICD/Pacemaker: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930487 -                Prosthetic Heart Valve: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930489 -               ..
930490 -              OTHER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930491 -                Tobacco:  No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930492 -                ETOH:  No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930494 -             ..
930495 -        2.  PHYSICAL ASSESSMENT:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930496 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930497 -            1.  Vitals - most recent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930498 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930499 -                Temp:96.7 F [35.9 C] (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930500 -                BP: 122/82 (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930501 -                HR: 60 (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930502 -                RR: 18 (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930503 -                WT: 173 lb [78.6 kg] (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930504 -                HT: 66 in [167.6 cm] (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930506 -                 ..
930507 -            2.  Mental Status: Alert, Oriented to: person, place,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930508 -                date, situation,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930510 -                 ..
930511 -            3.  Oriented to: situation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930513 -                 ..
930514 -            4.  Airway: Can patient open mouth wide? Yes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930515 -                Can patient stick out tongue? Yes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930516 -                Restricted movement of the neck? No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930517 -                Uvula fully visible when mouth open? Yes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930518 -                Comments:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930520 -                 ..
930521 -            5.  Lungs: CTA Bilaterally                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930523 -                 ..
930524 -            6.  Heart: REGULAR, NO MURMURS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930526 -                 ..
930527 -            7.  Exam specific to procedure:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930530 -             ..
930531 -   13.  Medications:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930533 -        Active Outpatient Medications (excluding Supplies):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930535 -         ..
930536 -        OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH        ACTIVE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930537 -        TWICE A DAY -15 MINUTES BEFORE MEALS FOR ACID                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930538 -        REFLUX.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930539 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930541 -         ..
930542 -   14.  Diagnostics: No new diagnostics reguired.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930544 -        Pertinent diagnostic data has been reviewed, significant                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930545 -        findings                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930546 -        below:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930548 -         ..
930549 -   15.  Date and time of last oral intake: Nov 15,2013@06:00                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930551 -         ..
930552 -   16.  Nature (type) and amount of last oral intake: See RN note                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930554 -         ..
930555 -   17.  SEDATION PLAN:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930556 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930557 -        Sedation/Anesthesia options, benefits, and risks were discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930558 -        including: nausea/vomiting, allergic reactions, unexpected                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930559 -        cardiac or pulmonary problems, and cardiac arrest.  Patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930560 -        expressed understanding and wishes to proceed with planned                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930561 -        sedation/anesthesia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930563 -         ..
930564 -   18.  Did a family member or companion accompany the patient and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930565 -        participate in the discussion and Interview?  No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930566 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930567 -   19.  /es/ RANDALL E LEE, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930568 -        STAFF PHYSICIAN, GASTROENTEROLOGY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930569 -        Signed: 11/15/2013 08:30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930570 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930571 -   20.  11/15/2013 ADDENDUM                         STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930572 -        EGD 1192432: TTS balloon engaged at 16.5mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930573 -        dilated to 18mm; triamcinolone 40mg/ml x 2ml injected.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930574 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930575 -   21.  /es/ RANDALL E LEE, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930576 -        STAFF PHYSICIAN, GASTROENTEROLOGY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930577 -        Signed: 11/15/2013 08:30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930578 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930579 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930580 - ********************************************                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930581 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930582 -    1.  LOCAL TITLE: Informed Consent 20303                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930583 -        STANDARD TITLE: PROCEDURE CONSENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930584 -        DATE OF NOTE: NOV 15, 2013@08:21:52 ENTRY DATE: NOV 15, 2013@08:22:14                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930585 -        AUTHOR: SALERA,RODELEI M       EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930586 -        URGENCY: STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930587 -        Signature Informed Consent for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930588 -        EGD WITH POSSIBLE INTERVENTIONS (VA) (ESOPHAGOGASTRODUODENOSCOPY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930589 -        (EGD) WITH POSSIBLE INTERVENTIONS)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930590 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930591 -        1.  Anatomical Location: EGD WITH DILATION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930593 -             ..
930594 -        2.  Informed consent was obtained at 8:21 AM on November 15,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930595 -            2013.  The full consent document can be accessed through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930596 -            Vista Imaging.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930598 -             ..
930599 -        3.  Patient name: WELCH, RODNEY CHARLES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930601 -             ..
930602 -        4.  The patient HAS decision-making capacity.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930604 -             ..
930605 -        5.  Surrogate (if applicable):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930607 -             ..
930608 -        6.  Reason for the treatment (diagnosis, condition, or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930609 -            indication):  To examine and treat the esophagus, stomach,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930610 -            and first part of small intestine for abnormalities and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930611 -            disease.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930613 -             ..
930614 -        7.  Treatment/procedure:  Upper GI endoscopy or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930615 -            esophagogastroduodenoscopy (EGD) is a procedure to look                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930616 -            at and treat problems in your esophagus (swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930617 -            tube), stomach, and first part of your small intestine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930618 -            (duodenum).  A flexible, steerable tube (endoscope) will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930619 -            be used.  This tube has a light, camera and openings for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930620 -            tools.  Before the procedure starts, your throat may be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930621 -            sprayed with some numbing medication.  After that, you                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930622 -            may be given medicine to make you sleepy (sedation).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930623 -            After you are sleepy, the tube will be passed through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930624 -            your mouth and into your esophagus, stomach, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930625 -            duodenum.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930627 -             ..
930628 -            Several things can be done with the endoscope, depending                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930629 -            on what is found.  These include:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930630 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930631 -            1.  Take photographs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930632 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930633 -            2.  Remove samples of tissue (biopsies).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930635 -                 ..
930636 -            3.  Remove growths.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930638 -                 ..
930639 -            4.  Control or prevent bleeding by injecting medicines,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930640 -                applying heat (cautery) or placing clips or rubber                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930641 -                bands.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930643 -                 ..
930644 -            5.  Stretch narrow areas with balloons or tapered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930645 -                plastic dilators.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930647 -                 ..
930648 -            6.  Other things the doctor thinks are necessary.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930650 -             ..
930651 -        8.  Moderate sedation will be used.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930653 -             ..
930654 -        9.  Consent to Blood Products (if applicable):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930655 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930656 -            It is not expected that blood products will be used in this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930657 -            treatment/procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930659 -             ..
930660 -       10.  Practitioner obtaining consent: Lee,Randall E (STAFF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930661 -            PHYSICIAN)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930663 -             ..
930664 -       11.  Supervising practitioner:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930666 -             ..
930667 -       12.  Practitioner(s) performing or supervising                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930668 -            treatment/procedure (if not listed above):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930670 -             ..
930671 -       13.  Witness Name(s):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930673 -             ..
930674 -       14.  Comments:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930676 -             ..
930677 -       15.  Comprehension Check Procedure2|DM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930679 -             ..
930680 -            *** SCANNED DOCUMENT ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930681 -            SIGNATURE NOT REQUIRED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930682 -            Electronically Filed: 11/15/2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930683 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930684 -            by:  IMED IMED-SERVER                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930685 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930686 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930687 - *************************************                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930688 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930689 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930690 -    1.  LOCAL TITLE: Gastroenterology Nurse Note 60133                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930691 -        STANDARD TITLE: GASTROENTEROLOGY NURSING NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930692 -        DATE OF NOTE: NOV 15, 2013@07:33 ENTRY DATE: NOV 15, 2013@07:33:34                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930693 -        AUTHOR: ABUYUAN,JOECIMEN EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930694 -        URGENCY:                   STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930696 -         ..
930697 -    2.  ADM TIME:  Nov 15,2013@07:33                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930699 -         ..
930700 -    3.  Vitals - most recent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930701 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930702 -        1.  Temp: 96.7 F [35.9 C] (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930703 -        2.  BP: 122/82 (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930704 -        3.  HR: 60 (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930705 -        4.  RR: 18 (11/15/2013 07:32) 02 Sat:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930706 -        5.  FBS: na                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930707 -        6.  RA/02@LPM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930708 -        7.  Pain: 0 (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930709 -        8.  Location:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930710 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930711 -        ********************************************************                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930713 -         ..
930714 -    4.  YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930715 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930716 -            1.  PATIENT ID: Verbal, ID Band, Chart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930718 -         ..
930719 -    5.  Allergies: Patient has answered NKA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930720 -        Allergy information verified: YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930721 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930722 -            2.  Nothing entered...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930724 -         ..
930725 -    6.  No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930726 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930727 -            3.  Advance Directive                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930728 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930729 -                a.  Patient has an Advance Directive in Medical Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930730 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930731 -                b.  Patient provided us with a copy of Advance                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930732 -                    Directive today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930733 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930735 -         ..
930736 -    7.  YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930737 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930738 -            4.  H&P in chart (within 30 days) Read & Reviewed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930740 -         ..
930741 -    8.  YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930742 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930743 -            5.  Consent Signed, Dated & Timed (within 30 days)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930745 -         ..
930746 -    9.  Patient verbally verified:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930748 -         ..
930749 -   10.  YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930750 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930751 -            6.  Correct Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930753 -         ..
930754 -   11.  YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930755 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930756 -            7.  NPO Since:Time & Date:Nov 14,2013@20:00                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930757 -                Last Solid Food: Nov 14,2013@16:00                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930759 -         ..
930760 -        NA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930761 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930762 -            8.  Bowel Prep Completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930763 -                Color of last Bowel Movement:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930764 -                Fleets enema given: N/A Time:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930765 -                Results: Administered By:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930767 -         ..
930768 -   12.  YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930769 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930770 -            9.  MD Orders, Nursing Assessment Completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930772 -         ..
930773 -   13.  YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930774 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930775 -           10.  Implants:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930776 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930777 -                Type:  cabg x 4 Locations:  chest                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930779 -         ..
930780 -   14.  YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930781 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930782 -           11.  Patient Valuables:  Gurney                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930783 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930784 -           12.  Skipped for some reason                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930786 -         ..
930787 -   15.  NO                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930788 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930789 -           13.  Dentures:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930791 -         ..
930792 -   16.  NO                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930793 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930794 -           14.  Glasses/Contact Lenses:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930796 -         ..
930797 -   17.  NO                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930798 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930799 -           15.  Skipped for some reason                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930801 -         ..
930802 -   18.  YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930803 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930804 -           16.  Driver/Escort Waiting If yes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930806 -                Name:  Cathy, sis in law                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930808 -         ..
930809 -   19.  YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930810 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930811 -           17.  Post Procedure Instructions Reviewed with Patient, Driver/Escort                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930812 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930813 -                Date of Interview: NOV 15, 2013 Patient Age: 68                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930814 -                Physician: lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930815 -                Procedure: egd                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930817 -         ..
930818 -   20.  Upon arrival patient was offered the option to don a hospital                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930819 -        gown and have an IV placed prior to seeing the GI practitioner.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930820 -        Patient verbally consented to don gown and have an IV placed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930822 -         ..
930823 -   21.  Patient was provided with a signaling device, and he/she was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930824 -        instructed to activate it at any time if he/she wishes to abort                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930825 -        the planned procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930827 -         ..
930828 -   22.  CURRENT MEDICATIONS TAKEN TODAY: None                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930830 -         ..
930831 -   23.  Are you using Fentanyl Patches? no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930832 -        If Yes, when was the last time applied?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930834 -         ..
930835 -   24.  Diabetic (IDDM): no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930836 -        Last dose:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930837 -        Diabetic (NIDDM): no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930839 -         ..
930840 -   25.  ASA: no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930841 -        Last dose:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930843 -         ..
930844 -   26.  NSAIDS: no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930845 -        Last dose:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930847 -         ..
930848 -   27.  Anti-platelets Therapy: no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
930850 -         ..
930851 -   28.  Anticoagulation Therapy: no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930853 -         ..
930854 -   29.  LOC:AAO                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930855 -        Cognitive Limitations: None                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930857 -         ..
930858 -   30.  Circ/Perfusion: Warm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930860 -         ..
930861 -   31.  Heart Tones: Distant                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930862 -        cabg x 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930863 -        Respirations: Regular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930865 -         ..
930866 -   32.  GI: Soft, Non-Tender, Bowel Sounds; present on omeprAZOLE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930867 -        GU: Voids w/o problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930868 -        Comments:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930870 -         ..
930871 -   33.  GYN: NA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930873 -         ..
930874 -   34.  Skin: Intact                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930875 -        Comments:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930877 -         ..
930878 -   35.  Musc/Skeletal/Activity: No abnormal finding Mobility:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930880 -         ..
930881 -   36.  Manual Dexterity:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930883 -         ..
930884 -   37.  Comments:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930886 -         ..
930887 -   38.  Behavioral/Emotional Status: Calm, Cooperative                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930888 -        Comments:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930890 -         ..
930891 -   39.  Barriers to Learning/Functional Assessment:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930892 -        Vision: Unimpaired                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
930894 -         ..
930895 -   40.  Hearing: Unimpaired                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
930897 -         ..
930898 -   41.  Communication: Normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930900 -         ..
930901 -   42.  Interpreter Required: no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930903 -         ..
930904 -   43.  Nutritional Assessment: Special Diet Restrictions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930905 -        HERE FOR EGD WITH DILATION. STAYS AWAY FROM MEAT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930907 -         ..
930908 -   44.  Cultural/Religious Preferences: none                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930910 -         ..
930911 -   45.  PLAN OF CARE - Pre-Procedure Sedation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930913 -         ..
930914 -   46.  Knowledge deficit related to impending procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930915 -        Outcomes:  Patient has adequate and appropriate information                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930916 -        related to pre-procedure, intra-procedure, and post-procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930918 -         ..
930919 -   47.  Instruct patient at initial visit that he/she must arrive with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930920 -        a responsible adult to transport them following the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930921 -        Procedure will be re-scheduled if arrangements not made.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930923 -         ..
930924 -   48.  Explain purpose of pre procedure sedation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930926 -         ..
930927 -   49.  Explain how conscious sedation works                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930929 -         ..
930930 -   50.  Explain monitoring of vital signs/patient pain status                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930931 -        throughout procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930933 -         ..
930934 -   51.  Enroll patient in procedure class                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
930936 -         ..
930937 -   52.  Above actions completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930939 -         ..
930940 -   53.  PLAN OF CARE - Intra- Procedure SEDATION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930941 -        Potential for anxiety related to possible pain during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930942 -        impending procedure and unfamiliar environment                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930944 -         ..
930945 -   54.  Outcomes:  Patient shows no signs of anxiety and verbalizes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930946 -        decreased level of anxiety during procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930948 -         ..
930949 -   55.  Allow private time 1 on 1 with patient to discuss fear or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930950 -        concerns                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930952 -         ..
930953 -   56.  Explain monitoring of vital signs/patient pain status                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930954 -        throughout procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930956 -         ..
930957 -   57.  Discuss medications and how patient is monitored                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930959 -         ..
930960 -   58.  Ask patient if he/she or someone he/she knows has ever had an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930961 -        untoward reaction to sedation ... encourage discussion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
930963 -         ..
930964 -   59.  Discuss any problems patient may have had with breathing,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
930965 -        airway obstruction in past.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930967 -         ..
930968 -   60.  Above actions completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930970 -  ..
930971 - Number 59 was not done in that there was no discussion of breathing,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930972 - airway obstruction, which occurred previously following CABG surgery,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930973 - reported on 091023 0445. ref SDS 17 01F9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930975 -  ..
930976 - Nurses Notes continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930977 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930978 -   61.  Potential for risk for altered gas exchange and ineffective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
930979 -        breathing patterns secondary to sedation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930980 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
930981 -   62.  Outcomes:  Patient will exhibit no signs of respiratory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
930982 -        distress and airway will remain patent throughout the procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
930984 -         ..
930985 -   63.  Nurse will assess current allergies and update documentation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930986 -        of allergies in CPRS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
930988 -         ..
930989 -   64.  Nurse will verify/maintain NPO status                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
930991 -         ..
930992 -   65.  Nurse will assure that all equipment in close proximity and in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
930993 -        working order prior to procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
930995 -         ..
930996 -   66.  Nurse administering conscious sedation will keep noise level                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
930997 -        to a minimum.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
930999 -         ..
931000 -   67.  Nurse will remain alert to subtle changes such as dyspnea,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
931001 -        hyperventilation, cyanosis, shortness of breath or stridor in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
931002 -        breathing patterns and possible drop in oxygen saturation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
931003 -        and/or hypotension keeping physician informed of patient status                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
931004 -        during procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
931006 -         ..
931007 -   68.  Above actions completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
931009 -         ..
931010 -   69.  Potential for actual pain during procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
931012 -         ..
931013 -   70.  Outcome:  Patient will verbalize or demonstrate relief of pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
931014 -        during and post-procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
931016 -         ..
931017 -   71.  Nurse will assess level of pain throughout the procedure and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
931018 -        administer analgesic as needed per order and evaluate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
931019 -        effectiveness.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
931021 -         ..
931022 -   72.  Above actions completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
931024 -         ..
931025 -   73.  PLAN OF CARE -Post- Procedure SEDATION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
931027 -         ..
931028 -   74.  Potential for altered level of consciousness or sensory motor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
931029 -        deficit at discharge                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
931031 -         ..
931032 -   75.  Outcome: Patient will remain free of injury and will be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
931033 -        oriented x 3 prior to discharge.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
931035 -         ..
931036 -   76.  Patient will be fully awake and oriented, exhibit the ability                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
931037 -        to cough and deep breath prior to discharge, ambulate with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
931038 -        steady gain as appropriate per pre-procedure, with minimal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
931039 -        pain, and minimal nausea.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
931041 -         ..
931042 -   77.  Above actions completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
931044 -         ..
931045 -   78.  Potential knowledge deficit for self care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
931047 -         ..
931048 -   79.  Outcome: Patient and/or caregiver will verbalize an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
931049 -        understanding of discharge instructions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
931051 -         ..
931052 -   80.  Discharge instructions will be provided to patient.  Nurse will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
931053 -        assure all questions are answered, and have patient repeat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
931054 -        instructions as they understood them.  Nurse will individualize                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
931055 -        teaching based on patients' ability to understand.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
931057 -  ..
931058 - This was not actually done.  Patient received a blank discharge form,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
931059 - unsigned.  Driving home, discussed with Kathy the doctor's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
931060 - post-procedure comments.  On arriving home, Kathy wrote down what she                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
931061 - recalled the doctor said, which is different from the patient's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
931062 - recollection, which was imparied from sedation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
931064 -  ..
931065 - Previously, when procedures were performed at the Martinez Clinic, the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
931066 - doctor entered discharge instructions and summarized key results,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
931067 - shown by the record on 110429 1230. ref SDS 78 DU6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
931069 -  ..
931070 - For prior procedures, the admitting attendant asked the patient to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
931071 - sign a blank discharge document before any work was performed.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
931072 - was refused, reported on 110429 1230. ref SDS 78 SR8M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
931074 -  ..
931075 - Nurses Notes continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
931076 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
931077 -   81.  Nurse will place follow-up call to patient the following work                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
931078 -        ay of procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
931080 -  ..
931081 - Josie said she or someone will call next Monday to follow up work                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
931082 - today.  She was advised patient will be traveling Sunday, and out of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
931083 - town until Thursday, 131121, and will get telephone messages at that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
931084 - time.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
931086 -  ..
931087 - Nurses Notes continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
931088 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
931089 -   82.  Assure patient doing well post-procedure, answer questions and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
931090 -        reinforce dates for follow-up, if any.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
931092 -         ..
931093 -   83.  Above actions completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
931094 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
931095 -   84.  /es/ Joecimen Abuyuan, BSN, RN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
931096 -        Staff Nurse, GI                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
931097 -        Signed: 11/15/2013 07:40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
931098 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
931099 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
931100 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
931101 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
9312 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
9403 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
9404 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
940401 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940402 -    1.  LOCAL TITLE: Gastroenterology Nurse Note 60133                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
940403 -        STANDARD TITLE: GASTROENTEROLOGY NURSING NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
940404 -        DATE OF NOTE: NOV 15, 2013@07:40 ENTRY DATE: NOV 15, 2013@07:40:40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
940405 -        AUTHOR: ABUYUAN,JOECIMEN EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
940406 -        URGENCY:                     STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
940408 -         ..
940409 -        Immediate Pre-Sedation Evaluation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
940411 -         ..
940412 -    2.  ASA Classification:  2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
940413 -    3.  NPO: Yes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940414 -    4.  Last ate: 11/15 1600                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
940415 -    5.  Driver: YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
940416 -    6.  Took Meds: No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
940417 -    7.  AM GLU: NA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
940418 -    8.  Off Aspirin: Yes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
940419 -    9.  Off NSAID: YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
940421 -         ..
940422 -   10.  Vital Signs:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
940423 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940424 -        1.  BP: 122/82 (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
940425 -        2.  Temp: 96.7 F [35.9 C] (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
940426 -        3.  Pulse: 60 (11/15/2013 07:32)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
940428 -         ..
940429 -   11.  Heart: CABG X 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
940430 -   12.  Lungs: WNL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
940431 -   13.  Implants: CABG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
940432 -   14.  ETOH use? No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
940433 -   15.  Chronic pain Medication use? No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
940434 -   16.  Drug use? No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
940435 -   17.  Tobacco use? No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
940437 -         ..
940438 -   18.  Additional Comments:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
940439 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940440 -        achalasia,fundoplication.  FOR EGD WITH possible repeat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
940441 -        dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940443 -         ..
940444 -        No change in medical condition since seen for anesthesia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940445 -        pre-op. Patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
940446 -        agrees to proceed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
940448 -         ..
940449 -   19.  A procedure was done using an endoscope with the following                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
940450 -        serial number                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
940451 -        [SCOPE 1]:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
940452 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940453 -            Serial#: GIF 4645                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
940454 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940455 -        /es/ Joecimen Abuyuan, BSN, RN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
940456 -        Staff Nurse, GI                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
940457 -        Signed: 11/15/2013 08:31                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940458 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940459 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940460 - *************************************                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
940461 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940462 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940463 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940464 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940465 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940466 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
940467 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
9405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Discharge Instructions Blank VA EGD Procedure Stricture Lower Esopha                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
A903 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
A90401 -  ..
A90402 - Discharge Instructions Blank No Signature No Date                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
A90403 - 
A90404 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90405 -    1.  LOCAL TITLE: GI Discharge Instructions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
A90407 -         ..
A90408 -    2.  VANCHCS GI Clinic Discharge Instructions::                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
A90410 -         ..
A90411 -    3.  -Do not drive a motor vehicle, operate machinery, or make                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
A90412 -        important decisions for at least 24 hours after your procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
A90413 -        The medication given during your procedure may make you dizzy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
A90414 -        and sleepy and will affect how you act and think.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
A90416 -         ..
A90417 -    4.  -You may resume a normal diet after you leave today unless                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
A90418 -        instructed otherwise.  However, for the first meal please eat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
A90419 -        light food, nothing greasy or spicy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
A90421 -         ..
A90422 -    5.  -During your procedure the doctor added air into your GI tract                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
A90423 -        so you may experience some abdominal bloating and cramping.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
A90424 -        The sooner you can pass the air the better you will feel.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
A90425 -        discomfort or bloating will subside in a few hours but may last                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
A90426 -        all day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90428 -         ..
A90429 -    6.  -If you have any of the following symptoms, please call the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
A90430 -        clinic at (916) 366-5339 for advice.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
A90431 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90432 -        A.  Passing or vomiting large amounts of blood.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
A90433 -        B.  Passing black or tarry stools.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
A90434 -        C.  Fever over 100 with or without chills.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
A90435 -        D.  Severe tenderness or redness at IV needle puncture                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
A90436 -            site.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
A90437 -        E.  Severe abdominal or chest pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
A90438 -        F.  Shortness of breath or tightness in the chest.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
A90439 -        G.  Loss of consciousness or frequent bouts of dizziness.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
A90440 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90442 -         ..
A90443 -    7.  -MEDICATIONS:  You may resume your medications after the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90444 -        procedure unless instructed otherwise by your physician.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90446 -         ..
A90447 -    8.  Resume ALL MEDS on Nov 15,2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
A90449 -         ..
A90450 -    9.  EGD, EUS, or Enteroscopy:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
A90452 -         ..
A90453 -   10.  -a mild sore throat can be helped by cough drops, or a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
A90454 -        salt-water gargle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
A90456 -         ..
A90457 -   11.  -Wait a half-hour after the exam before drinking liquids, as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
A90458 -        oral anesthetic may have been used to numb the throat.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
A90460 -         ..
A90461 -   12.  -Call or return to ER if difficulty swallowing or breathing,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
A90462 -        neck swelling, excessive pain, nausea or vomiting, abdominal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
A90463 -        distension, fever.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
A90465 -         ..
A90466 -   13.  GI Clinic phone number (916) 366-5339 (8:00am-4:30pm)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
A90467 -        After 4:30pm, weekends and holidays, please call (800) 382-8387                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
A90469 -         ..
A90470 -   14.  Follow Up:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
A90471 -        Primary Provider                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
A90473 -         ..
A90474 -   15.  POST-OP INSTRUCTION given to patient and responsible adult.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
A90475 -        Verbalized understanding.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
A90477 -         ..
A90478 -   16.  If you would like a copy of your procedure report, please                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
A90479 -        contact Release of Information (ROI) at (916) 843 7005.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
A90480 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90481 -        /es/ Laramie Samson, RN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
A90482 -        Staff Nurse, GI Clinic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
A90483 -        Signed: 11/15/2013 10:06                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90485 -  ..
A90486 - This part of the medical chart varies somewhat from Discharge form                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
A90487 - received after recovery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
A90489 -  ..
A90490 - The form is blank.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
A90492 -  ..
A90493 - Kathy wrote some notes from memory of Doctor Lee's discussion with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
A90494 - the patient.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
A90495 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90496 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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A90498 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90499 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90500 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A90502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
A906 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Letter VA Doctor Summary Results EGD Dilation Biopsy Medical Chart P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
AO03 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
AO0401 -  ..
AO0402 - Letter Doctor Summary Results EGD Dilation Biopsy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
AO0403 - 
AO0404 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
AO0405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
AO0406 -    1.  20 November 2013                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
AO0411 -         ..
AO0412 -    2.  You had an endoscopic examination of your esophagus, stomach,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
AO0413 -        and duodenum (EGD) with at the Sacramento VA Medical Center on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
AO0414 -        15 November 2013.  I'm pleased to report that the examination                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
AO0415 -        and biopsies showed NO cancer, precancerous changes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
AO0416 -        (dysplasia), ulcer, or infection.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
AO0418 -         ..
AO0419 -    3.  You continue to have some chronic inflammation of the stomach                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
AO0420 -        (gastritis) and esophagus, so we should continue the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
AO0421 -        acid-blocking medication (omeprazole) every day.  As we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
AO0422 -        discussed, please take the omeprazole twice a day for 1 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
AO0423 -        after the EGD and dilation, then you can reduce the omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
AO0424 -        to 20mg from twice a day to once a day, 15 to 30 minutes before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
AO0425 -        a meal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
AO0427 -         ..
AO0428 -    4.  We should repeat the EGD in about 6 months (about May 2014).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
AO0430 -         ..
AO0431 -    5.  My best wishes to you this holiday season, early Happy Birthday                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
AO0432 -        wishes, and congratulations again on your joining the "Half                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
AO0433 -        Dome Club."                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
AO0435 -         ..
AO0436 -        Truly yours,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
AO0437 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
AO0439 -         ..
AO0440 -        Randall E Lee, MD, FACP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
AO0441 -        Gastroenterologist, VA NCHCS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
AO0442 -        916-366-5339                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
AO0443 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
AO0444 -    6.  /es/ RANDALL E LEE, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
AO0445 -        STAFF PHYSICIAN, GASTROENTEROLOGY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
AO0446 -        Signed: 11/20/2013 08:58                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
AO0447 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
AO0448 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
AO0449 - ***************************************                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
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AO0464 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
AO0465 -