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: August 10, 2014 06:39 PM Sunday; Rod Welch

VA letter request EGD dilate LESV with triamcinolone injection.

1...Summary/Objective
2...Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
3...GI Department VA Sacramento Medical Center Administration EGD Dilation


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CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 16.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
4303 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4303 -    ..
4304 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
4305 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
430501 - Follow up ref SDS B1 0000. ref SDS A5 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
430502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
430503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
430504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
430505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
430506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
430508 -  ..
4306 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4307 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4308 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
4309 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
430901 - On 050629 meeting Primary Care swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
430902 - reported. ref SDS 1 K78K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
430904 -  ..
430905 - On 050714 barrium swallow test, ref SDS 2 2I4S, showed esophagus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
430906 - distorted by swallowing problems. ref SDS 2 WE4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
430908 -  ..
430909 - On 050816 meeting Primary Care Doctor Sandhu diagnoses achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
430910 - ref SDS 3 DG8G  Ultrasound test ordered to verify initial diagnosis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
430911 - swallowing and vomitting problems. ref SDS 3 6E7H  Primary Care made                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
430912 - referral to GI clinic for care to resolve swallowing problems.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
430913 - ref SDS 3 0G7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430915 -  ..
430916 - On 050830 ultrasound test evaluate swallowing problems possible                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
430917 - diagnosis achalasia. ref SDS 4 DG8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
430919 -  ..
430920 - On 050830 results received barrium swallow test performed on 050714,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430921 - findings in the lower espohagus and gastroesophageal junction are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
430922 - consistent with achalasia - recommend endoscopic examination.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
430923 - ref SDS 4 6H9S                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430925 -  ..
430926 - On 050906 report ultrasound test on 050830, finds no cause for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
430927 - swallowing problems and does not diagnose achalasia. ref SDS 5 BM6R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
430929 -  ..
430930 - On 051202 meeting GI Clinic Doctor Lee diagnoses achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
430931 - ref SDS 6 HP9H  Orders endoscopy (EGD) test to verify diagnosis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
430932 - achalasia and assess for cancer. ref SDS 6 NZ5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
430934 -  ..
430935 - On 051209 GI Clinic endoscopy examination preliminary findings no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
430936 - evidence of cancer, ref SDS 7 0001; biopsy report should be submitted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
430937 - in a few weeks to confirm status of cancer, ref SDS 7 PY5J, and if so,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
430938 - then a procedure can be schedule for next month to dilate the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
430939 - exophageal sphincter valve. ref SDS 7 NZ5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
430941 -  ..
430942 - On 051222 biopsy reports no evidence of cancer. ref SDS 8 FT6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430944 -  ..
430945 - On 060111 received letter from Doctor Lee in the Gastrointestinal (GI)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
430946 - Clinic reporting that the biopsy was negative for cancer and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
430947 - infection; next step is manometry test to verify achalasia, then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
430948 - treatment for achalasia. ref SDS 9 4Q3R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
430950 -  ..
430951 - On 060125 manomety test scheduled for 060209 0800. ref SDS 10 GG9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
430953 -  ..
430954 - On 060209 meeting at VA Mather AFB in Sacramento, test was postponed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430955 - until 060223, due to equipment failure. ref SDS 11 OW6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
430957 -  ..
430958 - On 060221 Jimmy in GI Department at Sacramento VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
430959 - reports manometry equipment still broken; has been sent out for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
430960 - repairs and there is no date at this time on when the equipment will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430961 - be available for use at the VA. ref SDS 12 ND7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
430963 -  ..
430964 - On 060330 endoscopy follow up examination at GI Department Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
430965 - Medical Center - Doctor Lee finds no evidence cancer performed at VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430966 - Sacramento condition precedent treatment recover from achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
430967 - ref SDS 13 VX4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
430969 -  ..
430970 - On 060330 manometry test performed by Doctor Lee at VA in Sacramento,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
430971 - ref SDS 13 MC7P, verifies diagnosis swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
430972 - caused by achalasia, ref SDS 13 MD4N, patient meets criteria for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
430973 - treatment with pneumatic dilation. ref SDS 13 MD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
430975 -  ..
430976 - On 060505 Martinez VA GI clinic Doctor Lee reported equipment and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
430977 - pneumatic balloon materials on hand to perform dilation for treating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430978 - achalasia; treatment delayed until diagnostic data is received from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
430979 - Sacramento VA Medical Center from manometry test performed on 060330;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
430980 - doctor following up to obtain data; will submit test data to patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430981 - during the week of 060508, along with a schedule to treat achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430982 - ref SDS 14 FT6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
430984 -  ..
430985 - On 060614 Martinez VA GI clinic reports increased work load treating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430986 - soldiers returning from war in Iraq requires prioritizing; patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
430987 - advocate, Rubin Soto, will coordinate with the GI Clinic notifying the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
430988 - customer of the schedule based on current priorities. ref SDS 15 J86N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
430990 -  ..
430991 - On 070220 letter to VA asks about progress getting test results from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430992 - VA in Sacramento, and scheduling surgery for achalasia, ref SDS 16                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
430993 - 5R5R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430995 -  ..
430996 - On 090812 1030 continued vomitting achalasia causes weight loss 30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
430997 - pounds in a few months, Primary Care physician notified GI clinic to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
430998 - review schedule for dilation to relieve achalasia. ref SDS 17 7L5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431000 -  ..
431001 - On 090908 meeting GI Clinic in Martinez reports treatment for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
431002 - achalasia still waiting to receive results for manometry test on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431003 - 060330, at Sacramento VA Medical Center. ref SDS 18 HX46  Prepared new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
431004 - work plan to treat achalasia without manometry test results, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431005 - the doctor performed the test 3 years ago, and is so knows results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
431006 - consistent with achalasia, shown on 060330 0712, ref SDS 13 MD4N;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
431007 - schedules treatment for achalasia after treadmill stress test,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431008 - ref SDS 18 BU6W, to evaluate new chest pains hiking hills at Lafayette                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
431009 - Reservoir which have not occurred doing extended exercise hiking 3 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431010 - 14 miles a day over the past 5 years. ref SDS 18 MY4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
431012 -  ..
431013 - On 091021 report history achalasia issue during meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
431014 - cardiothoracic surgery team to prepare for heart bypass surgery the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431015 - next day. ref SDS 20 NX6M  Surgery team will coordinate with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
431016 - anesthesia team to provide swallowing relief during heart surgery to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431017 - prevent choking. ref SDS 20 R78O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431019 -  ..
431020 - On 091022 0700 meeting anesthesia team - Doctor Brezinski not familiar                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431021 - with achalasia - asked if achalasia has been reported to the VA?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431022 - ref SDS 21 JF9K  While being prepared with IVs for surgery, patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431023 - assists anesthesia find VA records on achalasia, ref SDS 21 2W4K;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
431024 - Doctor Brezenski makes plans for patient care and safety so that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431025 - achalasia does not risk death during heart surgery. ref SDS 21 GX4J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431027 -  ..
431028 - On 091022 cabg x4 cardiothoracic surgery San Francisco Medical Center.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431029 - ref SDS 21 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431031 -  ..
431032 - On 091030 0800 at 1406 meeting with Doctor Stewart at San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431033 - Medical Center during recovery from heart surgery, proposes Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
431034 - Myotomy surgery rather than pneumatic (balloon) dilation as more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431035 - effective and longer lasting solution to recover from swallowing and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431036 - vomitting problems caused by achalasia. ref SDS 24 KE3B                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
431038 -  ..
431039 - On 091030 0800 at 1430 received documentation from GI Department at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431040 - San Francisco Medical Center - review shows 3 different treatments for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431041 - achalasia - pills, pneumatic dilation, Heller Myotomy surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431042 - ref SDS 24 495I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431044 -  ..
431045 - On 091030 0800 at 1440 meeting cardiothoracic surgery team; Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
431046 - Ratcliff concerned about how to maintain nutrition for the patient to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431047 - recover from heart surgery while digestion remains problematic due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431048 - achalasia; proposes feeding tube for several months until Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431049 - Myotomy surgery. ref SDS 24 03GF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431051 -  ..
431052 - On 091216 Heller Myotomy surgery at San Francisco VA Medical Center to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431053 - recover from achalasia. 091216 0600, ref SDS 36 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431055 -  ..
431056 - On 100202 meeting with Doctor Lee - report swallowing and vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431057 - problems 3 months after Heller Myotomy surgery.  Doctor explains                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431058 - achalasia disease breaks nerve connections from the brain that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431059 - contract the esophagus to force food and liquid from the mouth through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431060 - the esophagus; as well broken nerve connections prevent the lower                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
431061 - esophageal sphincter valve (LESV) to relax so that content can pass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431062 - into the stomach.  Without esophageal contractions, food and liquid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431063 - can only reach the stomach with gravity, but since the LESV won't                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
431064 - relax the patient continues to have swallowing and vomitting problems,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431065 - despite Heller Myotomy surgery on 091216, intended to maintain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431066 - adequate opening into the stomach. ref SDS 47 485W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431068 -  ..
431069 - On 100305 meeting at GI Clinic in Martinez, EGD procedure dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431070 - from 11 to 15 mm. ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
431072 -  ..
431073 - On 100827 meeting at GI Clinic in Martinez, EGD procedure dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431074 - from 11 to 15 mm. ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
431076 -  ..
431077 - On 101210 EGD procedure dilated esophageal sphincter valve (LESV)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
431078 - without sedation, ref SDS 67 BE7K - dilated LESV again from 11 to 14                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431079 - mm. ref SDS 67 BF6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431081 -  ..
431082 - On 101216 1021 letter commends medical team for excellent work, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431083 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431085 -  ..
431086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
431087 - anesthesia with Fentanyl. ref SDS 71 PQWY  LESV dilated 11 - 14 mm,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431088 - and added triamcinolone steriod injections to resist contraction of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431089 - LESV so that swallowing is maintained over the next 3 month cycle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
431090 - ref SDS 71 SR4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431092 -  ..
431093 - On 110429 0830 5th EGD dilation at VA in Martinez - triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
431094 - steriod injections worked well to resist contraction of LESV so that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431095 - swallowing was maintained over the prior 3 month cycle, ref SDS 75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 75 U23I, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431097 - triamcinolone injections were continued. ref SDS 75 SS5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431099 -  ..
431100 - On 110607 1414 visited GI Department, ref SDS 77 HC5H, and Charlene                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431101 - reported a computer mistakes requires scheduling next EGD dilation on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431102 - 110819 0830. ref SDS 77 N642  Requested meeting with Doctor Lee to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431103 - review pending action items. ref SDS 77 4P6J,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431105 -  ..
431106 - On 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431107 - valve.  Triamcinolone steriod injections worked well to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431108 - contraction of LESV so that swallowing is maintained over the prior 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431109 - month cycle, so LESV dilated from 15 - 16.5 mm, ref SDS 80 J978, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431110 - triamcinolone injections were continued. ref SDS 80 J985                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431112 -  ..
431113 - On 111115 1300 EGD dilation procedure - triamcinolone steriod injections                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431114 - worked well over the prior 3 month cycle, so LESV dilated from 16.5 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431115 - 18 mm, ref SDS 81 IR57; for some reason triamcinolone injections to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431116 - resist contraction of LESV was not performed. ref SDS 81 IS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431118 -  ..
431119 - On 120322 1030 EGD dilation procedure - swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431120 - increased without triamcinolone steriod injections on prior 3 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431121 - cycle. ref SDS 83 UI9H  LESV dilated from 16.5 - 18 mm. ref SDS 83                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431122 - 516N  Triamcinolone injections to resist contraction of LESV was not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431123 - performed. ref SDS 83 5179                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431125 -  ..
431126 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431127 - business unit; reported patient history. ref SDS 86 RG9K  Scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431128 - EGD and dilation procedure for 1300; returned and performed procedure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431129 - ref SDS 86 TB4J; dilated from 15 mm to 18 mm. ref SDS 86 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431130 - Swallowing and vomitting problems increased after omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431131 - triamcinolone steriod injections to resist contraction of LESV after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431132 - dilation, ref SDS 86 TZ4M; therefore, injections were resumed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431133 - complement dilation to enable and maintain effective swallowing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431134 - ref SDS 86 R87N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431136 -  ..
431137 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431138 - improvement recovering from acalasia, LESV contracted only slightly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431139 - from 18 mm down to 15 mm. ref SDS 94 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431141 -  ..
431142 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431143 - remained at 18 MM, ref SDS 99 CO5N, same as dialated 4 months earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
431144 - on 130110 0900. ref SDS 94 Q333  Report CT test on 130117, shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431145 - esophagus fully recovered from severe distortions caused by achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431146 - 8 years earlier. ref SDS 99 MT6F  Doctor Lee injected steriod again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
431147 - maintain swallowing. ref SDS 99 F38G  Prescribed reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431148 - to 1 pill per day. ref SDS 99 R74M  Scheduled next EDG dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431149 - months, instead of 3. ref SDS 99 6P6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
431151 -  ..
431152 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431153 - to 18 mm. ref SDS A5 CO5N  Triamcinolone steriod injected again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431154 - maintain improved swallowing. ref SDS A5 I167  Omeprazole medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431155 - maintained 20 mg taken morning and evening for 1 month, then reduce to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431156 - 20 mg once per day. ref SDS A5 R74M  Biopsies taken. ref SDS A5 3N8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431158 -  ..
431159 - On 131121 1604 ordered refill of Omeprazole to aid digestion.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431160 - is 1 refill remaining. ref SDS A6 YS4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
431162 -  ..
431163 - On 131205 1443 received order for Omeprazole prescription placed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431164 - 131121. ref SDS A7 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
431166 -  ..
431167 - On 140318 1043 received letter cancelling meeting scheduled for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431168 - EGD/Dilation procedure on 140425 1000, ref SDS A8 935L; a second                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431169 - letter scheduled prodedure on 140509 0900. ref SDS A8 5D7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431171 -  ..
431172 - On 140401 1659 ordered refill Omeprazole; none are remaining; need                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
431173 - Doctor Lee to order new prescription to increase refills. ref SDS A9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431174 - 4P5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431176 -  ..
431177 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431178 - center in Sacramento, Mather. ref SDS B1 K37G  Pre-op preperation went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
431179 - well - IV setup on first stick. ref SDS B1 EP75  Doctor ordered refills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
431180 - for Omeprazole. ref SDS B1 AW5O  Doctor patient partnership continues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
431181 - to progress with doctor reading up on patient history to be prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431182 - for effective meeting. ref SDS B1 ZZ6J  Doctor Lee recalled today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
431183 - having made timely referral for having heart surgery, enabling patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431184 - to recover and Half Dome 4 years later. ref SDS B1 0N6I  Reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
431185 - swallowing and vomitting problems reduced past 6 months with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
431186 - triamcinolone steriod injections to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431187 - ref SDS B1 VV6N  Doctor Lee dilated LESV contracted to only 16.5 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431188 - over past 6 months with triamcinolone steriod injections to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
431189 - contraction; he dilated LESV back to 18 MMy, ref SDS B1 5H5J, scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
431190 - next EGD dilation in 6 months since this worked well the past 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431191 - with triamcinolone steriod injections. ref SDS B1 549I  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431192 - explained that since there was no tearing of LESV during procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
431193 - today, triamcinolone steriod was not injected into LESV to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
431194 - contraction. ref SDS B1 I167  Progress notes report small tearing of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431195 - LESV during dilation procedure. ref SDS B1 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431197 -  ..
431198 - On 140805 letter to Doctor Lee requests consideration for early EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431199 - dilation with triamcinolone injection to resist contraction of LESV,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431200 - and if cancellation arises, but not emergency. ref SDS 0 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
431201 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431202 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431203 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431204 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431205 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431206 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431208 -  ..
4313 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4314 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
4315 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
431601 -  ..
431602 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
431603 - GI Department VA Sacramento Medical Center Administration EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
431604 - 
431605 - Follow up ref SDS B1 NU8L, ref SDS A5 NU8L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
431607 -  ..
431608 - VA website is at...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431609 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431610 -              https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431612 -  ..
431613 - Customer....                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
431617 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431625 -  ..
431626 - Sent letter to VA saying...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
431627 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431628 -    1.  Dear Doctor Lee:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
431630 -         ..
431631 -    2.  Vomiting has increased faster than past 2 dilations.  This is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431632 -        mostly inconvenience, and so does not require immediate action.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431633 -        However, if a cancellation arises, I would like to do another                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431634 -        dilation soonest, and with triamcinolone injection, which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431635 -        worked well with the prior dilations to resist contraction of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431636 -        LESV, as shown in patient history in the record on 140509 at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431637 -        line 550520, reviewing your progress notes. ref SDS B1 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431638 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
431639 -            [On 140819 0800 during meeting at VA Primary Care Clinic in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
431640 -            Martinez, Doctor Sandhu indicated Doctor Lee at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431641 -            Center in Sacramento will be notified about rising                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
431642 -            achalasia symptoms for consideration to advance EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431643 -            dilation procedure. ref SDS B5 EX78                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431645 -             ..
431646 -            [On 141014 0943 Kathy visited EGD Clinic at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431647 -            Center in Sacramento and talked to Lapria, who advised that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431648 -            on 141001, the VA responded to the letter on 140810, saying                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431649 -            EGD dilation is scheduled on 141121 1500 to implement order                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431650 -            for 6 months after prior procedure on 140509, which would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431651 -            be on 141109. ref SDS B6 NU8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431653 -         ..
431654 -    3.  You can track increased daily vomiting beginning last month on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431655 -        140712, shown in patient history see line 107301 (this may take                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431656 -        a minute to read into your browser. [...shown in case study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431657 -        120101 0900. ref SDS 82 4E4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
431659 -         ..
431660 -    4.  You can see as well, training for Half Dome scheduled next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
431661 -        month on 140917, has been interrupted by feet problems.  Met                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
431662 -        with Podiatry last week on 140805.  Radiology report that day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
431663 -        does not sound good.  Scheduled to meet the team again on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
431664 -        140820, to get further guidance.  Did 14 miles today, and made                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431665 -        that okay with Motrin, prescribed by Doctor Tang.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
431667 -         ..
431668 -    5.  Again, if feasible, would like to do LESV dilation with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
431669 -        triamcinolone injection soonest to relieve rising vomiting, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
431670 -        not emergency.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
431672 -         ..
431673 -    6.  Hope things are going well with you.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
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4317 -