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: May 9, 2014 09:00 AM Friday; Rod Welch

VA EGD dilate LESV to 18 mm order Omeprazole triamcinolone not injected.

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...Comprehensive Health Care Improves Doctor Read Progress Notes
8...Doctor Read Progress Notes on Cardiology Prepare for EGD Procedure
9...Swallowing Vomitting Difficulties Resolved with Triamciolone Injections
10...Triamcinoloe Injection Prevent LESV Contraction Avoid Swallowing Vomitting Problems
11...OR EGD Dilation with Application Lidocaine
12...EGD Dilation Procedure in OR Application Lidocaine
13...Dilated 18 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee
14...Meeting Doctor Lee Present Results EGD Dilation Procedure 18 MM
15...Results EGD Dilation Procedure Meeting Doctor Lee Present 18 MM
16...Progress Notes EGD Dilation Today
17...Ulceration LESV and Hiatal Hernia New Findings
18...Fundoplication Loosening Unravelling Failure
19...Addendum Progress Notes Biopsy Report
20...Biopsy Reports No Barrett's Esophabus Precursor to Cancer
21...Doctor Lee Letter Report Results EGD Dilation 140509


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CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 16.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
3903 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3903 -    ..
3904 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
3905 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
390501 - Follow up ref SDS A5 0000. ref SDS 99 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
390502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
390503 - EGD Dilation at VA medical center in Sacramento, Mather. ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
390504 - K37G  Pre-op preperation went well - IV setup on first stick.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
390505 - ref SDS 0 EP75  Doctor ordered refills for Omeprazole. ref SDS 0 AW5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
390506 - Doctor patient partnership continues to progress with doctor reading                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390507 - up on patient history to be prepared for effective meeting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
390508 - ref SDS 0 ZZ6J  Doctor Lee recalled today having made timely referral                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
390509 - for having heart surgery, enabling patient to recover and Half Dome 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
390510 - years later. ref SDS 0 0N6I  Reported swallowing and vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
390511 - problems reduced past 6 months with triamcinolone steriod injections                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390512 - to resist contraction of LESV. ref SDS 0 VV6N  Doctor Lee dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
390513 - contracted to only 16.5 MM over past 6 months with triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
390514 - steriod injections to resist contraction; he dilated LESV back to 18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390515 - MMy, ref SDS 0 5H5J, scheduled next EGD dilation in 6 months since                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
390516 - this worked well the past 6 months with triamcinolone steriod                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
390517 - injections. ref SDS 0 549I  After the procedure, the doctor reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390518 - there was no tearing of LESV during dilation of LESV, so triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
390519 - steriod was not injected into LESV to resist contraction. ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
390520 - I167  Progress notes report small tearing of LESV during dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
390521 - procedure. ref SDS 0 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
390522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
390523 -            [On 140810 1839 letter to Doctor Lee requesting EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
390524 -            dilation with triamcinolone injection soonest, if                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
390525 -            cancellation occurs; but, not an emergency, ref SDS B4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
390526 -            W83K, based on history rising vomitting swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
390527 -            problems, shown in patient history case study on 120101,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
390528 -            beginning 140712. ref SDS 82 4E4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
390530 -             ..
390531 -            [On 141107 0800 next EGD dilation was performed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
390532 -            ref SDS B8 NU8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
390533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
390534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
390535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
390536 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
390537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
390539 -  ..
3906 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3907 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3908 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
3909 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
390901 - On 050629 meeting Primary Care swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
390902 - reported. ref SDS 1 K78K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
390904 -  ..
390905 - On 050714 barrium swallow test, ref SDS 2 2I4S, showed esophagus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
390906 - distorted by swallowing problems. ref SDS 2 WE4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
390908 -  ..
390909 - On 050816 meeting Primary Care Doctor Sandhu diagnoses achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
390910 - ref SDS 3 DG8G  Ultrasound test ordered to verify initial diagnosis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
390911 - swallowing and vomitting problems. ref SDS 3 6E7H  Primary Care made                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
390912 - referral to GI clinic for care to resolve swallowing problems.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
390913 - ref SDS 3 0G7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390915 -  ..
390916 - On 050830 ultrasound test evaluate swallowing problems possible                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
390917 - diagnosis achalasia. ref SDS 4 DG8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
390919 -  ..
390920 - On 050830 results received barrium swallow test performed on 050714,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390921 - findings in the lower espohagus and gastroesophageal junction are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
390922 - consistent with achalasia - recommend endoscopic examination.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
390923 - ref SDS 4 6H9S                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390925 -  ..
390926 - On 050906 report ultrasound test on 050830, finds no cause for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
390927 - swallowing problems and does not diagnose achalasia. ref SDS 5 BM6R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
390929 -  ..
390930 - On 051202 meeting GI Clinic Doctor Lee diagnoses achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
390931 - ref SDS 6 HP9H  Orders endoscopy (EGD) test to verify diagnosis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
390932 - achalasia and assess for cancer. ref SDS 6 NZ5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
390934 -  ..
390935 - On 051209 GI Clinic endoscopy examination preliminary findings no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
390936 - evidence of cancer, ref SDS 7 0001; biopsy report should be submitted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
390937 - in a few weeks to confirm status of cancer, ref SDS 7 PY5J, and if so,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
390938 - then a procedure can be schedule for next month to dilate the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
390939 - exophageal sphincter valve. ref SDS 7 NZ5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
390941 -  ..
390942 - On 051222 biopsy reports no evidence of cancer. ref SDS 8 FT6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390944 -  ..
390945 - On 060111 received letter from Doctor Lee in the Gastrointestinal (GI)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
390946 - Clinic reporting that the biopsy was negative for cancer and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
390947 - infection; next step is manometry test to verify achalasia, then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
390948 - treatment for achalasia. ref SDS 9 4Q3R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
390950 -  ..
390951 - On 060125 manomety test scheduled for 060209 0800. ref SDS 10 GG9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
390953 -  ..
390954 - On 060209 meeting at VA Mather AFB in Sacramento, test was postponed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390955 - until 060223, due to equipment failure. ref SDS 11 OW6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
390957 -  ..
390958 - On 060221 Jimmy in GI Department at Sacramento VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
390959 - reports manometry equipment still broken; has been sent out for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
390960 - repairs and there is no date at this time on when the equipment will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390961 - be available for use at the VA. ref SDS 12 ND7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
390963 -  ..
390964 - On 060330 endoscopy follow up examination at GI Department Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
390965 - Medical Center - Doctor Lee finds no evidence cancer performed at VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390966 - Sacramento condition precedent treatment recover from achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
390967 - ref SDS 13 VX4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
390969 -  ..
390970 - On 060330 manometry test performed by Doctor Lee at VA in Sacramento,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
390971 - ref SDS 13 MC7P, verifies diagnosis swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
390972 - caused by achalasia, ref SDS 13 MD4N, patient meets criteria for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
390973 - treatment with pneumatic dilation. ref SDS 13 MD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
390975 -  ..
390976 - On 060505 Martinez VA GI clinic Doctor Lee reported equipment and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
390977 - pneumatic balloon materials on hand to perform dilation for treating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390978 - achalasia; treatment delayed until diagnostic data is received from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
390979 - Sacramento VA Medical Center from manometry test performed on 060330;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
390980 - doctor following up to obtain data; will submit test data to patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390981 - during the week of 060508, along with a schedule to treat achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390982 - ref SDS 14 FT6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
390984 -  ..
390985 - On 060614 Martinez VA GI clinic reports increased work load treating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390986 - soldiers returning from war in Iraq requires prioritizing; patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
390987 - advocate, Rubin Soto, will coordinate with the GI Clinic notifying the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
390988 - customer of the schedule based on current priorities. ref SDS 15 J86N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
390990 -  ..
390991 - On 070220 letter to VA asks about progress getting test results from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390992 - VA in Sacramento, and scheduling surgery for achalasia, ref SDS 16                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
390993 - 5R5R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390995 -  ..
390996 - On 090812 1030 continued vomitting achalasia causes weight loss 30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
390997 - pounds in a few months, Primary Care physician notified GI clinic to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
390998 - review schedule for dilation to relieve achalasia. ref SDS 17 7L5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
391000 -  ..
391001 - On 090908 meeting GI Clinic in Martinez reports treatment for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
391002 - achalasia still waiting to receive results for manometry test on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391003 - 060330, at Sacramento VA Medical Center. ref SDS 18 HX46  Prepared new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
391004 - work plan to treat achalasia without manometry test results, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391005 - the doctor performed the test 3 years ago, and is so knows results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391006 - consistent with achalasia, shown on 060330 0712, ref SDS 13 MD4N;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
391007 - schedules treatment for achalasia after treadmill stress test,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391008 - ref SDS 18 BU6W, to evaluate new chest pains hiking hills at Lafayette                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
391009 - Reservoir which have not occurred doing extended exercise hiking 3 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391010 - 14 miles a day over the past 5 years. ref SDS 18 MY4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
391012 -  ..
391013 - On 091021 report history achalasia issue during meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
391014 - cardiothoracic surgery team to prepare for heart bypass surgery the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391015 - next day. ref SDS 20 NX6M  Surgery team will coordinate with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391016 - anesthesia team to provide swallowing relief during heart surgery to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391017 - prevent choking. ref SDS 20 R78O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391019 -  ..
391020 - On 091022 0700 meeting anesthesia team - Doctor Brezinski not familiar                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391021 - with achalasia - asked if achalasia has been reported to the VA?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391022 - ref SDS 21 JF9K  While being prepared with IVs for surgery, patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391023 - assists anesthesia find VA records on achalasia, ref SDS 21 2W4K;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
391024 - Doctor Brezenski makes plans for patient care and safety so that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391025 - achalasia does not risk death during heart surgery. ref SDS 21 GX4J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391027 -  ..
391028 - On 091022 cabg x4 cardiothoracic surgery San Francisco Medical Center.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391029 - ref SDS 21 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391031 -  ..
391032 - On 091030 0800 at 1406 meeting with Doctor Stewart at San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391033 - Medical Center during recovery from heart surgery, proposes Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391034 - Myotomy surgery rather than pneumatic (balloon) dilation as more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391035 - effective and longer lasting solution to recover from swallowing and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391036 - vomitting problems caused by achalasia. ref SDS 24 KE3B                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
391038 -  ..
391039 - On 091030 0800 at 1430 received documentation from GI Department at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391040 - San Francisco Medical Center - review shows 3 different treatments for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391041 - achalasia - pills, pneumatic dilation, Heller Myotomy surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391042 - ref SDS 24 495I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391044 -  ..
391045 - On 091030 0800 at 1440 meeting cardiothoracic surgery team; Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391046 - Ratcliff concerned about how to maintain nutrition for the patient to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391047 - recover from heart surgery while digestion remains problematic due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391048 - achalasia; proposes feeding tube for several months until Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391049 - Myotomy surgery. ref SDS 24 03GF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391051 -  ..
391052 - On 091216 Heller Myotomy surgery at San Francisco VA Medical Center to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391053 - recover from achalasia. 091216 0600, ref SDS 36 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
391055 -  ..
391056 - On 100202 meeting with Doctor Lee - report swallowing and vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391057 - problems 3 months after Heller Myotomy surgery.  Doctor explains                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391058 - achalasia disease breaks nerve connections from the brain that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391059 - contract the esophagus to force food and liquid from the mouth through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391060 - the esophagus; as well broken nerve connections prevent the lower                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
391061 - esophageal sphincter valve (LESV) to relax so that content can pass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391062 - into the stomach.  Without esophageal contractions, food and liquid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391063 - can only reach the stomach with gravity, but since the LESV won't                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
391064 - relax the patient continues to have swallowing and vomitting problems,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391065 - despite Heller Myotomy surgery on 091216, intended to maintain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391066 - adequate opening into the stomach. ref SDS 47 485W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
391068 -  ..
391069 - On 100305 meeting at GI Clinic in Martinez, EGD procedure dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391070 - from 11 to 15 mm. ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
391072 -  ..
391073 - On 100827 meeting at GI Clinic in Martinez, EGD procedure dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391074 - from 11 to 15 mm. ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
391076 -  ..
391077 - On 101210 EGD procedure dilated esophageal sphincter valve (LESV)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
391078 - without sedation, ref SDS 67 BE7K - dilated LESV again from 11 to 14                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
391079 - mm. ref SDS 67 BF6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391081 -  ..
391082 - On 101216 1021 letter commends medical team for excellent work, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391083 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391085 -  ..
391086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
391087 - anesthesia with Fentanyl. ref SDS 71 PQWY  LESV dilated 11 - 14 mm,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391088 - and added triamcinolone steriod injections to resist contraction of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391089 - LESV so that swallowing is maintained over the next 3 month cycle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391090 - ref SDS 71 SR4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391092 -  ..
391093 - On 110429 0830 5th EGD dilation at VA in Martinez - triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
391094 - steriod injections worked well to resist contraction of LESV so that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391095 - swallowing was maintained over the prior 3 month cycle, ref SDS 75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
391096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 75 U23I, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391097 - triamcinolone injections were continued. ref SDS 75 SS5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391099 -  ..
391100 - On 110607 1414 visited GI Department, ref SDS 77 HC5H, and Charlene                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391101 - reported a computer mistakes requires scheduling next EGD dilation on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391102 - 110819 0830. ref SDS 77 N642  Requested meeting with Doctor Lee to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
391103 - review pending action items. ref SDS 77 4P6J,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391105 -  ..
391106 - On 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391107 - valve.  Triamcinolone steriod injections worked well to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391108 - contraction of LESV so that swallowing is maintained over the prior 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391109 - month cycle, so LESV dilated from 15 - 16.5 mm, ref SDS 80 J978, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
391110 - triamcinolone injections were continued. ref SDS 80 J985                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391112 -  ..
391113 - On 111115 1300 EGD dilation procedure - triamcinolone steriod injections                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
391114 - worked well over the prior 3 month cycle, so LESV dilated from 16.5 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391115 - 18 mm, ref SDS 81 IR57; for some reason triamcinolone injections to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391116 - resist contraction of LESV was not performed. ref SDS 81 IS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391118 -  ..
391119 - On 120322 1030 EGD dilation procedure - swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391120 - increased without triamcinolone steriod injections on prior 3 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391121 - cycle. ref SDS 83 UI9H  LESV dilated from 16.5 - 18 mm. ref SDS 83                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391122 - 516N  Triamcinolone injections to resist contraction of LESV was not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391123 - performed. ref SDS 83 5179                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391125 -  ..
391126 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
391127 - business unit; reported patient history. ref SDS 86 RG9K  Scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391128 - EGD and dilation procedure for 1300; returned and performed procedure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391129 - ref SDS 86 TB4J; dilated from 15 mm to 18 mm. ref SDS 86 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391130 - Swallowing and vomitting problems increased after omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
391131 - triamcinolone steriod injections to resist contraction of LESV after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391132 - dilation, ref SDS 86 TZ4M; therefore, injections were resumed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391133 - complement dilation to enable and maintain effective swallowing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391134 - ref SDS 86 R87N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391136 -  ..
391137 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391138 - improvement recovering from acalasia, LESV contracted only slightly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391139 - from 18 mm down to 15 mm. ref SDS 94 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391141 -  ..
391142 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
391143 - remained at 18 MM, ref SDS 99 CO5N, same as dialated 4 months earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
391144 - on 130110 0900. ref SDS 94 Q333  Report CT test on 130117, shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391145 - esophagus fully recovered from severe distortions caused by achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391146 - 8 years earlier. ref SDS 99 MT6F  Doctor Lee injected steriod again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
391147 - maintain swallowing. ref SDS 99 F38G  Prescribed reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
391148 - to 1 pill per day. ref SDS 99 R74M  Scheduled next EDG dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
391149 - months, instead of 3. ref SDS 99 6P6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
391151 -  ..
391152 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
391153 - to 18 mm. ref SDS A5 CO5N  Triamcinolone steriod injected again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
391154 - maintain improved swallowing. ref SDS A5 I167  Omeprazole medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
391155 - maintained 20 mg taken morning and evening for 1 month, then reduce to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391156 - 20 mg once per day. ref SDS A5 R74M  Biopsies taken. ref SDS A5 3N8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391158 -  ..
391159 - On 131121 1604 ordered refill of Omeprazole to aid digestion.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391160 - is 1 refill remaining. ref SDS A6 YS4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
391162 -  ..
391163 - On 131205 1443 received order for Omeprazole prescription placed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391164 - 131121. ref SDS A7 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
391166 -  ..
391167 - On 140318 1043 received letter cancelling meeting scheduled for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391168 - EGD/Dilation procedure on 140425 1000, ref SDS A8 935L; a second                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391169 - letter scheduled prodedure on 140509 0900. ref SDS A8 5D7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391171 -  ..
391172 - On 140401 1659 ordered refill Omeprazole; none are remaining; need                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391173 - Doctor Lee to order new prescription to increase refills. ref SDS A9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
391174 - 4P5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391176 -  ..
391177 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391178 - center in Sacramento, Mather. ref SDS 0 K37G  Pre-op preperation went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391179 - well - IV setup on first stick. ref SDS 0 EP75  Doctor ordered refills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391180 - for Omeprazole. ref SDS 0 AW5O  Doctor patient partnership continues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391181 - to progress with doctor reading up on patient history to be prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391182 - for effective meeting. ref SDS 0 ZZ6J  Doctor Lee recalled today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391183 - having made timely referral for having heart surgery, enabling patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391184 - to recover and Half Dome 4 years later. ref SDS 0 0N6I  Reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391185 - swallowing and vomitting problems reduced past 6 months with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
391186 - triamcinolone steriod injections to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391187 - ref SDS 0 VV6N  Doctor Lee dilated LESV contracted to only 16.5 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391188 - over past 6 months with triamcinolone steriod injections to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391189 - contraction; he dilated LESV back to 18 MMy, ref SDS 0 5H5J, scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391190 - next EGD dilation in 6 months since this worked well the past 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391191 - with triamcinolone steriod injections. ref SDS 0 549I  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
391192 - explained that since there was no tearing of LESV during procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391193 - today, triamcinolone steriod was not injected into LESV to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
391194 - contraction. ref SDS 0 I167  Progress notes report small tearing of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391195 - LESV during dilation procedure. ref SDS 0 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391196 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391197 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391198 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391199 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391201 -  ..
3913 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3914 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3915 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
391601 -  ..
391602 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391603 - GI Department VA Sacramento Medical Center Administration EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
391604 - 
391605 - Follow up ref SDS A5 NU8L, ref SDS 99 NU8L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
391606 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391607 - Meeting today implements planning in Progress Notes on 131115 0700.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391608 - ref SDS A5 O56M  Later, on 140318 received letter from VA scheduling                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
391609 - meeting today at 0900. ref SDS A8 GF9L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
391611 -  ..
391612 - Applied pre-proc requirements for NPO after midnight, from letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391613 - 101015 1547. ref SDS 59 4J9L  Last food was at......                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
391615 -  ..
391616 - Stayed at Kathy's place last night in Sacremento.  This morning, She                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391617 - drove us to VA Medical Center at Mather AFB.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
391619 -  ..
391620 - Checked into GI Department at the customer counter.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391621 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391622 -                         800-382-8387                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391623 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391624 -                         916 843 7000                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
391625 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391626 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391628 -  ..
391629 - Submitted Kathy's cell phone for designated driver.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
391633 -  ..
391634 - Kathy signed the discharge form affirming she will be designated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
391635 - driver, and responsible to facilitate no driving for 24 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391637 -  ..
391638 - Nurse at customer counter asked questions on patient history to verify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
391639 - ready for procedure, e.g., no allergies, and NPO after midnight to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
391640 - avoid conflicts with anesthesia; no health problems, e.g., no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
391641 - diabetes, alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
391643 -  ..
391644 - Waited in lobby for 5 minutes.  Then called to prepare for procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
391645 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
391647 -  ..
3917 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3918 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3919 - 0907                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3920 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392001 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392002 - 
392003 - Follow up ref SDS A5 RG9K, ref SDS 99 ZG3F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
392004 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392005 - This is different from prior procedures where vitals were initial case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392006 - setup prepared in a small office just off the lobby, and not in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392007 - treatment center, reported on 120925 0900. ref SDS 86 PT5P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392009 -  ..
392010 - The nurse took vitals...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
392011 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392012 -            Weight..................                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392013 -            BP...................... 132 71                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
392014 -            HR (pulse).............. 57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392015 -            Temp....................                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392017 -  ..
392018 - Denise did major prepartion work.  Configured on gurney and connected                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392019 - equipment to monitor vitals during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392021 -  ..
392022 - Doctor Lee walked into the prep room.  He smiled and waved but we did                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392023 - not talk at this point.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
392025 -  ..
392026 - Denise went through patient identification and medical profile                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
392027 - filling out forms on the computer.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392029 -  ..
392030 - Reported to Denise that Doctor Lee needs to order Omeprazole because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392031 - refills have expired, reported on 140401 1659. ref SDS A9 4P5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392033 -  ..
392034 - Denise confirmed that VA computer records shows refills have expired.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392036 -  ..
392037 - Another nurse was successful on 1st try getting blood flow for the IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392038 - setup needed to provide sedation.  This aligns with success on 1st                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392039 - attempt setting IV during procedure on 120925 0900, ref SDS 86 QZ5I,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
392040 - continuing success on 120322 1030, ref SDS 83 4Z9O, and previously                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
392041 - Iris's success setting an IV on the first try for procedure on 111115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392042 - 1300, ref SDS 81 4Z9O, and further corrects prior problems reported in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
392043 - study on 110429 1230. ref SDS 75 UN6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392045 -  ..
392046 - Waited about 30 minutes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
392047 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392048 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392050 -  ..
3921 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3922 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3923 - 1011                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3924 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392401 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
392402 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
392403 - 
392404 - Follow up ref SDS A5 ET4I, ref SDS 99 RG9K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
392405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392406 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392407 - procedure today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392409 -  ..
392410 - The doctor was aware from the note Denise entered that Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392411 - refills have expired, reported on 140401 1659. ref SDS A9 4P5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392412 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392413 -            [...below on 140509 0900 at 1130 after waking up from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392414 -            recovery following EGD dilation procedure, Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392415 -            advised he entered a new prescription on the VA refill                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392416 -            system with sufficient supply to increase taking Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392417 -            from 1 to 2 pills daily. ref SDS 0 JG4K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392419 -             ..
392420 -            [On 140715 1614 have 8 days supply of Omeprazole at current                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
392421 -            prescription taking 2 pills per day, so need to order                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392422 -            refill in time to receive Omeprazole before running out of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392423 -            pills.  Opened VA Pharmacy online medication refill system.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392424 -            ref SDS B1 5N3O  VA system shows 3 refills for Omeprazole,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392425 -            3 for Atorvastatin and 1 for Ezetimibe.  The system reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392426 -            "Refill in Process" with fill date of 140725 for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392427 -            Omeprazole. ref SDS B1 4O6H  If refill is mailed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392428 -            customer on 140725, then it may be received OA 140730.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392429 -            ref SDS B1 HX5O  Since there is no evident procedure to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
392430 -            update the VA processing schedule to fill the prescription,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392431 -            will take 1 pill per day until refill is received.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392432 -            ref SDS B1 IP6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392434 -  ..
392435 - Doctor Lee and his family have not returned to China since 2011, when                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392436 - they travelled there to adopt a baby.  His children are doing well.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392437 - Doctor Lee plans to hike Half Dome in the next few years, as his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392438 - children get old enough to make the effort.  He has a 15 year old                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392439 - daughter who likes camping, and does some hiking already.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
392440 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392442 -  ..
392443 - Comprehensive Health Care Improves Doctor Read Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
392444 - Doctor Read Progress Notes on Cardiology Prepare for EGD Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392445 - 
392446 - Follow up ref SDS A5 RG9K, ref SDS 86 UI3F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
392447 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392448 - The doctor requested pictures from the hike up Half Dome last year?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392450 -  ..
392451 - This request follows up the prior meeting 6 months ago when Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392452 - related having read Doctor Egan's Progress Notes on 131017, reporting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392453 - the patient hiked Half Dome the month before.  At that time, on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392454 - 131115, the doctor advised that he had reached the top of Half Dome                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392455 - hiking in Yosemite 20 years ago, as set out in the record on 131115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392456 - 0700. ref SDS A5 ET4I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392458 -  ..
392459 - It is unclear why the doctor would ask for pictures today, following                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392460 - up a brief discussion 6 months earlier.  He may have been reminded                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392461 - again of the patient hiking Half Dome from reading Doctor Egan's most                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392462 - recent Progress Notes for meeting in Cardiology on 140430, which both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392463 - incorporate the record hiking Half Dome last year, from the prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392464 - meeting in Cardiology on 131017, and further report the schedule to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392465 - Hike Half Dome again this year in September. ref SDS B0 5Z9J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392467 -  ..
392468 - Explained the record hiking Half Dome with pictures is on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392469 - Internet.  If we could communicate efficiently through conventional                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392470 - correspondence with electronic mail, the doctor could receive high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392471 - speed electrical connections that make reviewing high volume, complex                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392472 - records fast and easy, which supports other doctors on the medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392473 - team, including Doctor Egan, shown by incorporating patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392474 - correspondence into the Progress Notes, shown on 140430 0900.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392475 - ref SDS B0 788I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392476 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392477 -            [...below on 140509 0900 at 1040 arranged for Doctor Lee to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
392478 -            see pictures hiking Half Dome in Yosemite Valley, and prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392479 -            to commencement of GI dilation procedure in the OR.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
392480 -            ref SDS 0 LX7L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
392482 -  ..
392483 - Doctor Lee commented to the nurse how he made referral for evaluation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392484 - of chest pains from hiking at Lafayette Reservoir, reported on 090908                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392485 - 1130. ref SDS 18 MY4N  It was touching that he remembered this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392486 - episode 5 years ago.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392488 -  ..
392489 - Commended and thanked Doctor Lee again for work plan with timely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392490 - referral to another department, before going forward with EGD and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392491 - dilation work that was the purpose of the meeting on 090908.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
392492 - ref SDS 18 BU6W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392493 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392495 -  ..
392496 - Swallowing Vomitting Difficulties Resolved with Triamciolone Injections                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
392497 - Triamcinoloe Injection Prevent LESV Contraction Avoid Swallowing Vomitting Problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392498 - 
392499 - Follow up ref SDS A5 CX4G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392500 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392501 - Doctor Lee asked about swallowing and vomitting?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392503 -  ..
392504 - Today, reported that swallowing remains generally good after dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392505 - to 18 mm and applying triamcinolone during the prior meeting on 131115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392506 - 0700. ref SDS A5 CO5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392508 -  ..
392509 - In the past 6 weeks experiencing slight build up in esohpagus (throat)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392510 - a few times when eating, and which has caused slight vomitting.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392511 - remains significantly improved compared to prior severe swallowing and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392512 - vomitting problems.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392514 -  ..
392515 - On a few occassions have taken 2 Omeprazole pills in one day to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392516 - relieve stomach distress, otherwise taking 1 pill per day works well.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392518 -  ..
392519 - There have been 2 or 3 occassions while hiking 11 miles that stomach                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392520 - disorder occurs.  Continuing hiking releives the problem.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
392522 -  ..
392523 - In recent weeks saliva tends to build up in the esophagus, so this is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392524 - a good time to do another dilation with triamcinolone steriod                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392525 - injections, which resists contraction of LESV, so that effective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392526 - swallowing is maintained much longer than without injecting steriods,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392527 - as shown in Progress Notes on 111115 1300. ref SDS 81 AW6J and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392528 - reported again in Progress Notes on 120925 0900. ref SDS 86 E558                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392530 -  ..
392531 - Made a joke about betting LESV will engage at about 16mm today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392533 -  ..
392534 - Signed consent for the procedure, which is not visible - there is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392535 - merely a back screen to sign.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392537 -  ..
392538 - We agreed next meeting should be in 6 months, since swallowing and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392539 - vomitting problems have been minimal with triamcinolone steriod                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392540 - injections, shown by case study...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392541 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392542 -                LESV Dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392543 -                Date   from - to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392544 -                131115   16.5 18.....triamcinolone.... ref SDS A5 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392545 -                130416   18   18.....triamcinolone.... ref SDS 99 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392546 -                130110   15   18.....triamcinolone.... ref SDS 94 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392547 -                120925   15   18.....triamcinolone.... ref SDS 86 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392548 -                120322   16.5 18...................... ref SDS 83 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392549 -                111115   16.5 18...................... ref SDS 81 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392550 -                110819   15   16.5...triamcinolone.... ref SDS 80 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392551 -                110429   13   16.5...triamcinolone.... ref SDS 75 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392552 -                110218   11   14.....triamcinolone.... ref SDS 71 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392553 -                101210   11   14...................... ref SDS 67 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392554 -                100827   11   15...................... ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392555 -                100305   11   15...................... ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392557 -             ..
392558 -            [On 140810 1839 letter to Doctor Lee requesting EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392559 -            dilation with triamcinolone injection soonest, if                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
392560 -            cancellation occurs; but, not an emergency, ref SDS B4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
392561 -            W83K, based on history rising vomitting swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392562 -            problems, shown in patient history case study on 120101,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392563 -            beginning 140712. ref SDS 82 4E4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392564 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392565 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392567 -  ..
3926 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3927 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3928 - 1040                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3929 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392901 - OR EGD Dilation with Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392902 - EGD Dilation Procedure in OR Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392903 - 
392904 - Follow up ref SDS A5 CX4G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392905 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392906 - Denise wheeled the gurney into the OR for the procedure.  Met                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392907 - Brianna.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
392909 -  ..
392910 - Doctor Lee had to go upstairs to check on another patient admitted to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392911 - the hospital, so we had a few minutes to talk, while Brianna completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392912 - preparations to begin the EGD/Dilation procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392914 -  ..
392915 - Mentioned Doctor Lee's request a few minutes ago before being wheeled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392916 - into the OR, to see pictures of the Half Dome hike last year, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392917 - above. ref SDS 0 ZZ6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392919 -  ..
392920 - Brianna explained that she visited Yosemite this past Memorial Day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392921 - Her dad has a house in Groveland, very near Yosemite Village.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392922 - Mentioned that Kathy and I had lunch in Groveland on the way driving                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392923 - into the valley to hike Half Dome last year, reported on 130917 0830.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392924 - ref SDS A2 R64N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392926 -  ..
392927 - Brianna said she has not hiked Half Dome, but does other hiking in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392928 - Yosemite park.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
392930 -  ..
392931 - Asked if she has access to the Internet from the computer in the OR,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392932 - and so could access the record for the hike for Doctor Lee?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392934 -  ..
392935 - Brianna was very kind using the computer in the OR to access the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
392936 - record of the hike on 130918 0620. ref SDS A3 0001  She scrolled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392937 - through to find the picture at the top of Half Dome. ref SDS A3 2D4K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
392939 -  ..
392940 - Brianna saw the picture at the Trail Head near Happy Isle, and which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
392941 - shows the High Sierra Loop Trail that includes Glacier Point.  She                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392942 - said they hiked to Glacier Point on her visit a few weeks ago.  Asked                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
392943 - if there is an actual glacier at that location.  Brianna said there is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392944 - no glacier, and further noted the snow level is much lower than in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
392945 - past years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
392947 -  ..
392948 - Doctor Lee returned to the OR.  He took a moment to check the pictures                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392949 - of the Half Dome hike, which Brianna had accessed on the computer, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
392950 - his request earlier. ref SDS 0 ZZ6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392952 -  ..
392953 - This was a good moment showing pictures in the VA OR of the patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
392954 - hiking Half Dome, and for whom Doctor Lee initiated heart surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392955 - (CABG +4) 5 years ago on 090908 1130, ref SDS 18 MY4N, and following                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
392956 - up Doctor Lee's comments earlier today, per above. ref SDS 0 0N6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
392958 -  ..
392959 - The team then did the EDG/dilation procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
392960 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392961 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
392963 -  ..
3930 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3931 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
3932 - 0946                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
3933 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
393301 - Dilated 18 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
393302 - Meeting Doctor Lee Present Results EGD Dilation Procedure 18 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
393303 - Results EGD Dilation Procedure Meeting Doctor Lee Present 18 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
393304 - 
393305 - Follow up ref SDS A5 5H5J, ref SDS 99 5R4N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
393307 -  ..
393308 - An hour or so after the procedure, met with Doctor Lee in the recovery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393309 - room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393311 -  ..
393312 - LESV contracted to only 16.5 mm since prior dilation 6 months ago on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393313 - 131115 0700, ref SDS A5 RZ45, and with triamcinolone steriod injection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
393314 - at that time on 131115 0700. ref SDS A5 V35G. ref SDS A5 V35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
393316 -  ..
393317 - Doctor Lee proposed that since prior injection of triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393318 - steriod has worked well to aid swallowing and avoid vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393319 - the past 6 months, the next EGD dilation can be deferred for another 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393320 - months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
393322 -  ..
393323 - Agreed to this work plan.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
393325 -  ..
393326 - Doctor Lee then advised that he did not apply triamcinolone steriod                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393327 - again today to maintain improved swallowing, even though this has been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393328 - effective for the past 2 years, since 120925...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393329 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393330 -                LESV Dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393331 -                Date   from - to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393332 -                140509   16.5 18...................... ref SDS 0 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393333 -                131115   16.5 18.....triamcinolone.... ref SDS A5 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393334 -                130416   18   18.....triamcinolone.... ref SDS 99 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393335 -                130110   15   18.....triamcinolone.... ref SDS 94 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393336 -                120925   15   18.....triamcinolone.... ref SDS 86 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393337 -                120322   16.5 18...................... ref SDS 83 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393338 -                111115   16.5 18...................... ref SDS 81 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393339 -                110819   15   16.5...triamcinolone.... ref SDS 80 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393340 -                110429   13   16.5...triamcinolone.... ref SDS 75 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393341 -                110218   11   14.....triamcinolone.... ref SDS 71 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393342 -                101210   11   14...................... ref SDS 67 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393343 -                100827   11   15...................... ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393344 -                100305   11   15...................... ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393346 -  ..
393347 - Doctor Lee seemed to say during the meeting that triamcinolone steroid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393348 - injection was not done today, because there were no tears in LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
393349 - observed during the dilation procedure that caused bleeding.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
393350 - showed photographs taken during the procedure, and explained                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
393351 - professional interpretation finds no tears in LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393352 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393353 -            [...below on 140509 0900 Progress Notes are silent on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393354 -            triamcinolone steriod injection - nothing is said except                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393355 -            "...a small amount of mucosal tearing" occurred dilating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393356 -            LESV, ref SDS 0 P680, which appears conflicting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393357 -            understandings from post-procedure discussion with the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
393358 -            doctor seeming to indicate that triamcinolone injection was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393359 -            not done because there was no tearing, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
393360 -            ref SDS 0 O36G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
393362 -             ..
393363 -            [On 140718 1017 called Doctor Lee's nurse, Lapria; she will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
393364 -            notify Doctor Lee to call about advancing next EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393365 -            to resolve swallowing problems shown by increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
393366 -            vomitting. ref SDS B3 PH53                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393368 -             ..
393369 -            [On 140819 0800 during meeting at VA Primary Care Clinic in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
393370 -            Martinez, Doctor Sandhu indicated Doctor Lee at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393371 -            Center in Sacramento will be notified about rising                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
393372 -            achalasia symptoms for consideration to advance EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
393373 -            dilation procedure. ref SDS B5 EX78                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393375 -             ..
393376 -            [On 141107 2000 Doctor Lee explained that triancinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393377 -            steroid injection was omitted for the procedure on 140509                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393378 -            to test resisting contraction of LESV without the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
393379 -            injection. ref SDS B6 VV6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393381 -  ..
393382 - Omitting triamcinolone injections to resist contraction of LESV so                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393383 - that normal swallowing is maintained through the coming 6 month cycle,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393384 - seems like another experiment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
393385 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393386 -            [On 141107 2000 Doctor Lee seemed to report that omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
393387 -            triamcinolone steriod injection for procedure on 140509,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393388 -            was an "experiment" to test patient tolerance for reducing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393389 -            line of care, based on evident recovery. ref SDS B7 G89K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
393391 -  ..
393392 - Triamcinolone steriod was first injected into LESV to help prevent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393393 - contraction, which had caused severe swallowing and vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
393394 - problems, reported on 110218 0730. ref SDS 71 SR4G  This was done                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
393395 - again on 110429, because the doctor found less contraction of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393396 - following prior injection and so continued practice of injecting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
393397 - steriod. ref SDS 75 SS5N  On 110819 triamcinolone steriod was again                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
393398 - injected into LESV. ref SDS 80 SS5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
393400 -  ..
393401 - Progress Notes for EGD Dilation procedure on 110819, cite improved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393402 - swallowing which greatly reduces vomitting was accomplished by adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393403 - triamcinolone injections that resist contraction of LESV following                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393404 - dilations. ref SDS 80 QRXQ  This appears to validate the work plan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
393405 - developed on 110218, to improve results treating achalasia by adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393406 - triamcinolone injections to LESV, after severe swallowing problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393407 - were reported with dilation and Omeprazole only. ref SDS 71 EN6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393409 -  ..
393410 - Despite favorable results reported on 110819, adding triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393411 - injections, during the next EGD Dilation procedure on 111115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
393412 - Triamcinolone steriod was not injected, shown in Progress Notes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
393413 - ref SDS 81 IS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393415 -  ..
393416 - Doctor Lee further found in Progress Notes on 111115, that patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393417 - responded well to combining Omeprazole, dilation and triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393418 - steriod injection. ref SDS 81 AW6J  There is no explanation for why                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
393419 - favorable response to treatment with triamcinolone ending swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393420 - and vomitting problems justified ending treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393422 -  ..
393423 - After omitting traimcinolone steriod injection on 111115, case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393424 - on 101010 shows vomitting resumed, indicating difficulty swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393425 - due to contraction of LESV, shown in the record of meeting for EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393426 - dilation on 120322 1030. ref SDS 83 UI9H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
393428 -  ..
393429 - For some reason, triamcinolone injection was omitted again on 120322                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393430 - 1030, ref SDS 83 5179, despite evident rise of swallowing and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393431 - vomitting problems near the end of 4 month treatment period.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
393432 - ref SDS 83 UI9H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393434 -  ..
393435 - Triamcinolone steriod injection was done again on 120925 0900,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
393436 - ref SDS 86 R87N, because swallowing and vomitting problems continued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
393437 - to increase near the end of 6 month period. ref SDS 86 GW66                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
393439 -  ..
393440 - As a result of poor performance on ending triamcinolone steriod                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393441 - injection on 111115, ref SDS 81 IS6L, and again on 120322, ref SDS 83                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
393442 - 5179, the prior protocol injecting triamcinolone steriod into LESV to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393443 - resist contraction was not performed again on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
393444 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393445 -            [On 141107 2000 Doctor Lee seemed to report that omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
393446 -            triamcinolone steriod injection for procedure on 140509,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393447 -            was an experiment. ref SDS B7 G89K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393449 -  ..
393450 - Doctor Lee seemed to say something about changing Omeprazole protocol                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393451 - from 1 pill per day to 2 pills, and that he revised the VA refill                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
393452 - prescription order for Omeprazole to support this increase in daily                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393453 - quantity, followig up discussion this morning that VA pharmacy system                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393454 - shows there are no remaining refills, per above. ref SDS 0 AW5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393456 -  ..
393457 - Was not sure if the work plan is the same as last time, to take 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
393458 - pills per day for a month, then reduce back to 1 per pill as ordered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393459 - during the prior meeting on 131115 0700. ref SDS A5 R74M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
393461 -  ..
393462 - The Progress Notes should clarify this issue.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
393463 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393464 -            [...below on 140509 0900 Progress Notes are silent on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393465 -            triamcinolone steriod injection - nothing is said except                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393466 -            "...a small amount of mucosal tearing" occurred dilating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393467 -            LESV, ref SDS 0 P680, which appears conflicting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393468 -            understandings from post-procedure discussion with the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
393469 -            doctor seeming to indicate that triamcinolone injection was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
393470 -            not done because there was no tearing, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
393471 -            ref SDS 0 O36G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
393473 -             ..
393474 -            [On 140715 1614 now have 8 days supply remaining, so tried                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
393475 -            to order refill; VA system shows "Refill in Process" and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393476 -            scheduled to be filled in 10 days on 140725, ref SDS B1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
393477 -            5N3O, and so will be delivered in 3+ days, OA 140730.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
393478 -            Since cannot communicate with VA EGD Department, will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
393479 -            reduce treatment to 1 pill per day until prescription is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
393480 -            refilled sometime after 140725. ref SDS B1 IP6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
393482 -             ..
393483 -            [On 140801 in case study on 120101, Omeprazole not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
393484 -            delivered; implement fasting regimen to increase immunity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393485 -            and lower weight, ref SDS 82 NW6I; aligns with prior delays                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
393486 -            getting Omeprazole refill issued by VA on 140725, reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393487 -            on 140715 1614, ref SDS B1 4O6H, and prescribed on 140509,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
393488 -            to take 2 pills a day for achalasia - relieve acid burn                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393489 -            that inflames LESV, ref SDS 0 JG4K, confirmed Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
393490 -            Notes. ref SDS 0 P43G  Call to VA on 140718 to expedite                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
393491 -            delivery asked if necessary to continue taking pills when                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393492 -            supply runs out. ref SDS B2 U76M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
393494 -             ..
393495 -            [On 140819 0800 during meeting at VA Primary Care Clinic in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
393496 -            Martinez, Doctor Sandhu indicated Doctor Lee at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
393497 -            Center in Sacramento will be notified about rising                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
393498 -            achalasia symptoms for consideration to advance EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
393499 -            dilation procedure. ref SDS B5 EX78                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
393500 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
393506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
3936 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Medical Chart Progress Notes VA EGD Procedure Stricture Lower Esopha                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
5203 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520401 -  ..
520402 - Progress Notes EGD Dilation Today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520403 - 
520404 - Follow up ref SDS A5 CY7I, ref SDS 99 CY7I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
520405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520406 - On 140725 VA file for Progress Notes meeting with Doctor Lee on 140509                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520407 - were finally available for download from VA computer through the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520408 - Internet.   The notes were received OA 140808, through the US mail,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520409 - from VA Martinez Clinic ROI Department for request entered OA 140515.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520411 -  ..
520412 - VA website is at...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520413 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520414 -              https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520415 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520430 -    1.  LOCAL TITLE: EGD 60111                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520431 -        STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520432 -        DATE OF NOTE: MAY 09, 2014@09:00 ENTRY DATE: MAY 12, 2014@14:50:19                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
520433 -        AUTHOR: LEE,RANDALL E EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520434 -        URGENCY: STATUS: COMPL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520435 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520436 -    2.  *** EGD 60111 Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520438 -         ..
520439 -    3.  PATIENT NAME:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520444 -         ..
520445 -    4.  NAME OF PROCEDURES:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520446 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520447 -        1.  Esophagogastroduodenoscopy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520448 -        2.  Endoscopic biopsy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520449 -        3.  TTS balloon dilation of esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520451 -         ..
520452 -    5.  ATTENDING PHYSICIAN:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520453 -        Randall E. Lee, M.D.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520455 -         ..
520456 -    6.  INDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520459 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520460 -        1.  69-year-old man with a history of achalasia.  He underwent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520461 -            laparoscopic myotomy and fundoplication at the San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520462 -            Francisco VA Medical Center, but then developed acid reflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520463 -            and a recurrent distal esophageal stricture.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
520465 -             ..
520466 -        2.  His last EGD and dilation was November 2013, at which time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520467 -            he had some small mucosal tearing at 18 mm balloon                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520468 -            inflation.  He underwent a triamcinolone injection at that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520469 -            time.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520471 -             ..
520472 -        3.  Since then, he was initially on omeprazole 20 mg twice                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520473 -            daily, which has been dropped down to maintenance therapy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520474 -            at 20 mg once daily.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520476 -             ..
520477 -        4.  He has occasionally used 20 mg twice daily for breakthrough                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520478 -            symptoms.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520480 -             ..
520481 -        5.  Recently he has noted some dysphagia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520483 -             ..
520484 -        6.  He has a co-diagnosis of coronary artery disease and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520485 -            underwent coronary artery bypass graft prior to his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520486 -            fundoplication and myotomy.  He has remained without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520487 -            cardiac symptoms and is planning a repeat climb to the top                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520488 -            of Half Dome this summer.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520490 -         ..
520491 -    7.  CONSENT:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520492 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520493 -        The risks, benefits, and alternatives to this procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520494 -        including but not limited to the risks of bleeding and bowel                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520495 -        perforation were explained to the patient.  The patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520496 -        understood and provided a written informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520498 -         ..
520499 -    8.  INTRAVENOUS MEDICATION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520500 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520501 -        1.  Diphenhydramine 50 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520502 -        2.  Fentanyl 200 mcg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520503 -        3.  Midazolam 5 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520505 -            [On 141107 0800 Pentanyl 150 mcg was reduced from 200 mcg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520506 -            for procedure on 140509. ref SDS B9 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
520508 -  ..
520509 - Patient Medical History is shown in Progress Notes for meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520510 - Doctor Egan in Cardiology on 140430 0900. ref SDS B0 TX50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520512 -  ..
520513 - Progress Notes EGD Dilation procedure on 140509 continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520514 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520515 -    9.  PROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520516 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520517 -        1.  In the Sacramento VA GI Endoscopy Unit, the patient was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520518 -            placed in the left lateral decubitus position.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
520520 -             ..
520521 -        2.  Oxygen at 2 liters per minute by nasal cannula was administered.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520523 -             ..
520524 -        3.  Continuous oximetric and hemodynamic monitoring was initiated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
520526 -             ..
520527 -        4.  Intravenous sedation was administered in divided doses.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520529 -             ..
520530 -        5.  After a bite block was placed in the patient's mouth, an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520531 -            Olympus GIF-H180J video gastroscope was advanced under                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520532 -            direct vision into the esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520534 -             ..
520535 -        6.  At approximately 39 cm was a mild esophageal narrowing with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520536 -            associated ulceration.  This did not impede passage of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520537 -            diagnostic endoscope.  The endoscope was then advanced into                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520538 -            the descending duodenum.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520540 -             ..
520541 -        7.  Retroflexed views of the incisura, fundus, and cardia were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520542 -            performed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520544 -                 ..
520545 -            <P676P37J
520546 -        8.  Random biopsies were taken from the GE junction at 39 cm,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520547 -            labeled A.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520549 -             ..
520550 -        9.  The TTS balloon dilator was then advanced across the distal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520551 -            esophagus and inflated sequentially to 15, 16.5, and 18 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520552 -            As visualized through the balloon, there was minimal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520553 -            contact with mucosa at 15 mm, circumferential contact at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520554 -            16.5, and a small amount of mucosal tearing at 18 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520555 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520556 -                LESV Dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520557 -                Date   from - to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520558 -                140509   16.5 18...................... ref SDS 0 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520559 -                131115   16.5 18.....triamcinolone.... ref SDS A5 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520560 -                130416   18   18.....triamcinolone.... ref SDS 99 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520561 -                130110   15   18.....triamcinolone.... ref SDS 94 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520562 -                120925   15   18.....triamcinolone.... ref SDS 86 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520563 -                120322   16.5 18...................... ref SDS 83 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520564 -                111115   16.5 18...................... ref SDS 81 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520565 -                110819   15   16.5...triamcinolone.... ref SDS 80 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520566 -                110429   13   16.5...triamcinolone.... ref SDS 75 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520567 -                110218   11   14.....triamcinolone.... ref SDS 71 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520568 -                101210   11   14...................... ref SDS 67 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520569 -                100827   11   15...................... ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520570 -                100305   11   15...................... ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520572 -  ..
520573 - Reporting "small amount of mucosal tearing at 18 mm" was previously                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520574 - reported for prior procedure on 131115, ref SDS A5 RZ45, at that time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520575 - on 131115, triamcinolone steriod was injected into LESV to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520576 - contraction for 6 months. ref SDS A5 V35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520578 -  ..
520579 - After the procedure today, the doctor seemed to say triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520580 - steriod was not injected today, because no tearing was observed during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520581 - the dilation procedure, per above. ref SDS 0 O36G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520583 -  ..
520584 - The doctor reports in Findings best estimate of LESV contraction since                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520585 - prior dilation is 16.5. ref SDS 0 P396                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520587 -  ..
520588 - Unlike prior Progress Notes the doctor does not say triamcinolone was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520589 - injected into LESV, e.g., prior procedure on 131115 0700, ref SDS A5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520590 - V35G; nor, that triamcinolone injection was not done, as shown for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520591 - procedure on 120322 1030. ref SDS 83 5179                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520593 -  ..
520594 - Since the doctor seemed to report during a meeting after the procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520595 - that triamcinolone was not injected today, per above, ref SDS 0 I167,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520596 - and since there is no affirmative report that injecion occurred, this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520597 - study assumes no injection.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520598 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520599 -                LESV Dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520600 -                Date   from - to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520601 -                140509   16.5 18...................... ref SDS 0 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520602 -                131115   16.5 18.....triamcinolone.... ref SDS A5 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520603 -                130416   18   18.....triamcinolone.... ref SDS 99 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520604 -                130110   15   18.....triamcinolone.... ref SDS 94 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520605 -                120925   15   18.....triamcinolone.... ref SDS 86 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520606 -                120322   16.5 18...................... ref SDS 83 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520607 -                111115   16.5 18...................... ref SDS 81 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520608 -                110819   15   16.5...triamcinolone.... ref SDS 80 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520609 -                110429   13   16.5...triamcinolone.... ref SDS 75 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520610 -                110218   11   14.....triamcinolone.... ref SDS 71 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520611 -                101210   11   14...................... ref SDS 67 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520612 -                100827   11   15...................... ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520613 -                100305   11   15...................... ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520615 -             ..
520616 -            [On 140718 1017 called Doctor Lee's nurse, Lapria; she will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520617 -            notify Doctor Lee to call about advancing next EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520618 -            to resolve swallowing problems shown by increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520619 -            vomitting. ref SDS B3 PH53                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520621 -             ..
520622 -            [On 140810 1839 letter to Doctor Lee requesting EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520623 -            dilation with triamcinolone injection soonest, if                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520624 -            cancellation occurs; but, not an emergency, ref SDS B4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
520625 -            W83K, based on history rising vomitting swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520626 -            problems, shown in patient history case study on 120101,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520627 -            beginning 140712. ref SDS 82 4E4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520629 -             ..
520630 -            [On 140819 0800 during meeting at VA Primary Care Clinic in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520631 -            Martinez, Doctor Sandhu indicated Doctor Lee at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520632 -            Center in Sacramento will be notified about rising                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520633 -            achalasia symptoms for consideration to advance EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520634 -            dilation procedure. ref SDS B5 EX78                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520636 -             ..
520637 -            [On 141107 2000 Doctor Lee explained that triancinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520638 -            steroid injection was omitted for the procedure on 140509                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520639 -            to test resisting contraction of LESV without the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520640 -            injection. ref SDS B6 VV6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520642 -  ..
520643 - Progress Notes EGD Dilation procedure on 140509 continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520644 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520645 -       10.  The stomach was decompressed and the gastroscope removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520647 -         ..
520648 -   10.  COMPLICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520649 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520650 -        None.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520652 -  ..
520653 - Ulceration LESV and Hiatal Hernia New Findings                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520654 - 
520655 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520656 -   11.  FINDINGS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520657 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520658 -        1.  Previous area of esophageal stricture again identified at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520659 -            the 39 cm distance.  The best estimation of starting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520660 -            diameter is greater than 16.5 mm but less than 18mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520662 -             ..
520663 -        2.  Shallow ulceration immediately after the GE junction, which was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520664 -            biopsied, labeled specimen A.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520666 -  ..
520667 - Ulceration was not reported in findings during prior procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520668 - 131115 0700. ref SDS A5 PY6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520669 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520670 -               [On 150421 1210 EGD dilation found ulcerations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520671 -               regressing (improving) to mere erosions. ref SDS C1 PXXY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520673 -  ..
520674 - Progress Notes continue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520675 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520676 -        3.  Gastric fundus surgically altered consistent with known history of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520677 -            fundoplication.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520679 -             ..
520680 -        4.  Hiatal hernia identified.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520682 -  ..
520683 - Seems like new condition, since no prior report of "hiatal hernia,"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520684 - shown by Findings from prior Progress Notes on 131115 0700.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520685 - ref SDS A5 PY6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520686 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520687 -               [On 150319 0800 meeting with Doctor Lee indicated acid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520688 -               reflux increased causing ulceration that increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520689 -               constriction to LESV that hampers swallowing, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520690 -               fundoplication has unraveled, i.e., failed, further                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520691 -               causing hiatal hernia, ref SDS B0 N535; remedy -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520692 -               referral to Doctor Stewart to assess re-fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520693 -               or other measures. ref SDS B0 JQ5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520695 -  ..
520696 - Progress Notes EGD Dilation procedure on 140509 continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520697 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520698 -        5.  Normal pylorus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520700 -             ..
520701 -        6.  Normal duodenum to D2.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520703 -         ..
520704 -   12.  IMPRESSION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520705 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520706 -        1.  Gastroesophageal reflux stricture with minor recurrence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520707 -            since the prior examination and dilation in November 2013.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520708 -            The appearance of the ulceration suggests the patient would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520709 -            benefit from an increased dose of proton pump inhibitor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520710 -            therapy on a daily basis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520712 -  ..
520713 - Fundoplication Loosening Unravelling Failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520714 - 
520715 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520716 -        2.  Appearance of hiatal hernia suggests the fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520717 -            appears to be loosening.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520719 -  ..
520720 - Associating fundoplication loosening with hiatal hernia aligns with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520721 - new findings reported today, including ulceration, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520722 - ref SDS 0 P396                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520724 -  ..
520725 - "Fundoplication appears to be loosening" seems like a new condition,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520726 - since prior EGD dilation procedure reported that "fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520727 - remains intact," shown in the record on 131115 0700. ref SDS A5 JW4I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520728 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520729 -               [On 150319 0800 meeting with Doctor Lee indicated acid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520730 -               reflux increased causing ulceration that increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520731 -               constriction to LESV that hampers swallowing, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520732 -               fundoplication has unraveled, i.e., failed, further                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520733 -               causing hiatal hernia, ref SDS C0 N535; remedy -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520734 -               referral to Doctor Stewart to assess re-fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520735 -               or other measures. ref SDS C0 JQ5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520737 -  ..
520738 - Progress Notes EGD Dilation procedure on 140509 continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520739 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520740 -   13.  RECOMMENDATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
520741 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520742 -        1.  Increase omeprazole to 20 mg twice daily and maintain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520743 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520744 -               [On 140801 in case study on 120101, Omeprazole not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520745 -               delivered; implement fasting regimen to increase                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520746 -               immunity and lower weight, ref SDS 82 NW6I; aligns with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520747 -               prior delays getting Omeprazole refill issued by VA on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520748 -               140725, reported on 140715 1614, ref SDS B1 4O6H, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
520749 -               prescribed on 140509, to take 2 pills a day for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520750 -               achalasia - relieve acid burn that inflames LESV,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520751 -               ref SDS 0 JG4K, confirmed Progress Notes. ref SDS 0 P43G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520752 -               Call to VA on 140718 to expedite delivery asked if                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520753 -               necessary to continue taking pills when supply runs out.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520754 -               ref SDS B2 U76M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520756 -             ..
520757 -        2.  Repeat EGD and dilation in approximately 6 months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520759 -             ..
520760 -        3.  Await the pathology results.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
520761 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520762 -            [On 141107 0800 next EGD dilation was performed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520763 -            ref SDS B8 NU8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520765 -         ..
520766 -   14.  DISPOSITION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520767 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520768 -        1.  The patient was observed in the Recovery Room then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
520769 -            discharged to home with a companion.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520770 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520771 -        2.  I reviewed the endoscopic findings with the patient prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520772 -            to discharge.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520774 -         ..
520775 -   15.  TIME START:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520776 -        1050 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520777 -        TIME END:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520778 -        1104 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520779 -        D: 05/09/2014                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520780 -        T: 05/09/2014                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
520781 -        Job number: 1267078                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520782 -        AXG/CMTS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520783 -        $end:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520784 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520785 -   16.  /es/ Randall E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520786 -        Staff Physician, Gastroenterology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520787 -        Signed: 05/13/2014 17:56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520788 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520789 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520791 -  ..
520792 - Addendum Progress Notes Biopsy Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520793 - Biopsy Reports No Barrett's Esophabus Precursor to Cancer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
520794 - 
520795 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520796 -    1.  05/13/2014 ADDENDUM STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520798 -         ..
520799 -    2.  Microscopic exam/diagnosis: (Date Spec taken: May 09, 2014)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520801 -         ..
520802 -    3.  GASTROESOPHAGEAL JUNCTION, 39CM (BIOPSY):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520803 -        - SQUAMOCOLUMNAR MUCOSA WITH CHRONIC INFLAMMATION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520804 -        - NEGATIVE FOR INTESTINAL METAPLASIA (BARRETT'S ESOPHAGUS)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520806 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520808 -  ..
520809 - Doctor Lee Letter Report Results EGD Dilation 140509                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520810 - 
520811 - Doctor Lee's post-procedure letter received a week or so after the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520812 - procedure, and incoporated into Progress Notes, says...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
520814 -         ..
520815 -    1.  In Reply Refer To: Sacramento VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
520816 -        Gastroenterology (111/SMAT)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520823 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520824 -    2.  13 May 2014                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520828 -         ..
520829 -    3.  You had an endoscopic examination of your esophagus,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520830 -        stomach, and duodenum (EGD) at the Sacramento VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520831 -        Center 9 May 2014.  The biopsies show NO cancer,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
520832 -        precancerous changes (dysplasia), or infection.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
520834 -         ..
520835 -    4.  The biopsies of your esophagus continue confirmed some acid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
520836 -        damage, so please continue to take your acid blocking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
520837 -        medication (omeprazole) at the increased dose of 20 mg twice                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520838 -        a day every day as prescribed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
520840 -         ..
520841 -    5.  I'll see you in about six months. Best wishes on your next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
520842 -        ascent of Half Dome.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
520843 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520844 -            [On 141107 0800 next EGD dilation was performed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520845 -            ref SDS B8 NU8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
520847 -         ..
520848 -    6.  Truly yours,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520850 -         ..
520851 -    7.  Randall E. Lee, MD, FACP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
520852 -        Gastroenterologist, VA NCHCS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520853 -        916-366-5339                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
520854 -        /es/ Randall E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
520855 -        Staff Physician, Gastroenterology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
520856 -        Signed: 05/13/2014 18:02                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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5209 -