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
520857 -
520858 -
520859 -
520860 -
520861 -
520862 -
520863 -
520864 -
520865 -
520866 -
520867 -
520868 -
520869 -
520870 -
520871 -
5209 -