CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 15
4303 -
4303 - ..
4304 - Summary/Objective
4305 -
430501 - Follow up ref SDS B1 0000. ref SDS A5 0000.
430502 -
430503 - Met with Doctor Lee at VA Medical Center in Sacramento (Mather).
430504 - Checking in and initial administration went well. ref SDS 0 GD4H
430505 - Preparation for the procedure was very professional as usual; however,
430506 - there was difficulty setting IV for conscious sedation - required 3
430507 - sticks today. ref SDS 0 5W5I Good discussion with Doctor Lee guided
430508 - by agenda submitted for the meeting today to facilitate collaboration
430509 - through doctor patient partnership. ref SDS 0 VV6N The doctor
430510 - explained increased difficulty swallowing this cycle occurred because
430511 - of experiment to evaluate omitting triamcinalone steriod injection on
430512 - prior procedure performed 140507. ref SDS 0 4U8I EGD dilation LESV
430513 - from 15 mm back to 18 mm because triamcinalone steriod was not
430514 - injected during prior procedure on 140509. ref SDS 0 T55I Progress
430515 - Notes report findings of ulceration and hiatal hernia. ref SDS 0 MG6N
430516 - Photographs taken today seem to show significantly different condition
430517 - of fundoplication from a year ago. ref SDS 0 I74I
430519 - ..
430520 - [On 141125 0942 letter to the VA notifies Doctor Lee that
430521 - Progress Notes sometimes fail to post to patient medical
430522 - records on VA computer system, when the file includes an
430523 - addendum. ref SDS C0 GN75
430525 - ..
430526 - [On 150115 1110 visited VA Medical Center in Sacramento and
430527 - met with Jessica, an admin attendant for GI Clinic; she
430528 - could not find Progress Notes for EGD dilation procedure on
430529 - 141107, in patient medical records on the VA computer
430530 - system; she will notify Doctor Lee and discuss with
430531 - supervising nurse to expedite filing the Progress Notes
430532 - required by VA regulations for completing patient care.
430533 - ref SDS C1 MX5I
430535 - ..
430536 - [On 150116 0813 met with Jessica at GI Clinic VA Medical
430537 - Center in Sacramento, she has notified Doctor Lee that
430538 - Progress Notes are missing for EGD Dilation on 141107,
430539 - ref SDS C2 MX5I; later that day at 0922 Doctor Lee called
430540 - and left voicemail message that his Progress Notes for the
430541 - EGD Dilation procedure on 141107, are missing from VA
430542 - medical records computer system; he further said the
430543 - missing Progresss Notes can be restored by scanning another
430544 - source; he will have the records restored and submit notice
430545 - to the patient when his Progress Notes can be downloaded
430546 - using the Internet to access the VA computer system.
430547 - ref SDS C2 ZX6I
430548 -
430549 -
430550 -
430551 -
430553 - ..
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 140718 1017 planning for notifying VA to update current fill date
431199 - for Omeprazole. ref SDS B4 U88L Kathy visited VA in Sacramento, and
431200 - requested changing refill date for Omeprazole to 140718. ref SDS B4
431201 - OL5K VA representative called customer, and said Doctor Lee would
431202 - call back later that day to consider action on updating scheduled
431203 - refill date of Omeprazole to 140718. ref SDS B4 U76M
431205 - ..
431206 - On 140810 1839 letter to Doctor Lee requesting EGD dilation with
431207 - triamcinolone injection soonest, if cancellation occurs; but, not an
431208 - emergency, ref SDS B6 W83K, based on history rising vomitting
431209 - swallowing problems, shown in patient history case study on 120101,
431210 - beginning 140712. ref SDS 82 4E4M
431212 - ..
431213 - On 140819 0800 during meeting at VA Primary Care Clinic in Martinez,
431214 - Doctor Sandhu indicated Doctor Lee at VA Medical Center in Sacramento
431215 - will be notified about rising achalasia symptoms for consideration to
431216 - advance EGD dilation procedure. ref SDS B7 EX78
431218 - ..
431219 - On 141014 0943 Kathy visited VA Medical Center in Sacramento and met
431220 - with Lapria again, who advised that the VA responded in a letter on
431221 - 141001, to the letter on 140810, and further scheduled a meeting with
431222 - Doctor Lee on 141121 1530. ref SDS B8 QJ5N
431224 - ..
431225 - On 141103 2152 submitted agenda for meeting with Doctor Lee at VA
431226 - Sacramento Medical Center on 141107 0800, for next EGD dilation.
431227 - ref SDS B9 K37G Submit record showing normal swallowing occurs longer
431228 - with triamcinolone steriod injection to resist contraction of LESV.
431229 - ref SDS B9 3U97 Request schedule next EGD dilation in 4 months, and
431230 - if LESV does not contract, then schedule following EGD dilation in 6
431231 - months. ref SDS B9 3U66 Notified results of Half Dome hike.
431232 - ref SDS B9 3U6Y
431233 -
431234 -
431235 -
431236 -
431237 -
431238 -
431240 - ..
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 B9 NU8L, ref SDS B1 NU8L.
431606 -
431607 - Meeting today implements planning in Progress Notes on 140509 0900.
431608 - ref SDS B1 LG9L
431610 - ..
431611 - On 141103, submitted agenda for the meeting today. ref SDS B9 K37G
431613 - ..
431614 - Applied pre-proc requirements for NPO after midnight, from letter on
431615 - 101015 1547. ref SDS 59 4J9L Last food was at......
431617 - ..
431618 - Stayed at Kathy's place last night in Sacremento. This morning, She
431619 - drove us to VA Medical Center at Mather AFB.
431621 - ..
431622 - Checked into GI Department at the customer counter.
431623 -
431624 - 800-382-8387
431625 -
431626 - 916 843 7000
431627 -
431628 -
431630 - ..
431631 - Submitted Kathy's cell phone for designated driver.
431635 - ..
431636 - Kathy signed the discharge form affirming she will be designated
431637 - driver, and responsible to facilitate no driving for 24 hours.
431639 - ..
431640 - Nurse at customer counter asked questions on patient history to verify
431641 - ready for procedure, e.g., no allergies, and NPO after midnight to
431642 - avoid conflicts with anesthesia; no health problems, e.g., no
431643 - diabetes, alcohol, cigarettes.
431645 - ..
431646 - Waited in lobby for 5 minutes. Then called to prepare for procedure.
431647 -
431649 - ..
4317 -
4318 -
4319 - 0907
4320 -
432001 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
432002 -
432003 - Follow up ref SDS B9 EP75, ref SDS B1 EP75.
432004 -
432005 - This is different from prior procedures where vitals were initial case
432006 - setup prepared in a small office just off the lobby, and not in the
432007 - treatment center, reported on 120925 0900. ref SDS 86 PT5P
432009 - ..
432010 - The nurse took vitals...
432011 -
432012 - Weight.................. 186
432013 - BP...................... 132 71
432014 - HR (pulse).............. 57
432015 - Temp....................
432017 - ..
432018 - Denise did major prepartion work. Configured on gurney and connected
432019 - equipment to monitor vitals during the procedure.
432021 - ..
432022 - Gale set catheter IV for sedation. Required 3 tries, so difficult
432023 - day. This is the first time in several years that catheter required
432024 - more than one stick, shown in case study on 110429 1230. ref SDS 75
432025 - UO3G
432027 - ..
432028 - As occurred previously on 110429, on removing the failed catheters,
432029 - the puncture wounds began bleeding, and required a special bandage.
432030 - Marry noted anomoly of blood failing through the catheter needle, but
432031 - flowing freely from the needle puncture. As before, catheter was
432032 - finally set on top of left hand.
432034 - ..
432035 - Denise went through patient identification and medical profile
432036 - filling out forms on the computer.
432038 - ..
432039 - Waited about 30 minutes.
432040 -
432041 -
432043 - ..
4321 -
4322 -
4323 - 1011
4324 -
432401 - Consent Signed EGD Dilation and Meeting Review Pending Issues
432402 - Consultation Pending Issues and Sign Consent for EGD Dilation
432403 -
432404 - Follow up ref SDS B9 RG9K, ref SDS B1 RG9K.
432405 -
432406 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation
432407 - procedure today.
432408 -
432410 - ..
432411 - Swallowing Vomitting Difficulties Resolved with Triamcinolone Injections
432412 - Triamcinolone Injection Prevent LESV Contraction Avoid Swallowing Vomitting Problems
432413 -
432414 - Follow up ref SDS B9 VV6N, ref SDS B1 VV6N.
432415 -
432416 - Doctor Lee seemed familiar with the letter to the VA on 141103,
432417 - submitting the agenda for the meeting today performing EGD dilation
432418 - that resolves difficult swallowing with increased vomitting beginning
432419 - in July. ref SDS B9 K37G The letter on 141103 cited prior request for
432420 - immediate care on 140718 1017, ref SDS B3 U76M; follow up letter using
432421 - VA online communication system was submitted on 140810 1839,
432422 - ref SDS B5 LW4I, another verbal request for care was made on 141014
432423 - 0943. ref SDS B8 QJ5N
432425 - ..
432426 - The doctor explained that omitting Triamcinolone steroid injection for
432427 - the procedure on 140509, ref SDS B1 I167, was an experiment to test
432428 - LESV resisting contraction without steriod injection.
432430 - ..
432431 - This report aligns with analysis in the record on 140509, concluding
432432 - that omitting triamcinolone injection was an experiment. ref SDS B1
432433 - R26H
432434 -
432435 - [On 150120 1636 letter to Doctor Lee encourages continuing
432436 - to "experiment" on improving care, and to give notice of
432437 - experiments so that timely feedback can be provided on
432438 - results. ref SDS C3 VE60
432440 - ..
432441 - Advised that without triamcinolone steroid injection swallowing became
432442 - difficult in July, and so on 140810, submitted letter requesting EGD
432443 - dilation if cancellation occurred, but the issue at no time was an
432444 - emergency that required immediate care, as set out in the letter to
432445 - the VA on 140810 1839, ref SDS B5 W83K, and confirmed in the recent
432446 - letter on 141103 2152. ref SDS B9 K37G
432447 -
432448 - [On 150116 0813 at 0922 Doctor Lee called and left
432449 - voicemail message - pleased hearing that returning to
432450 - adding triamcinolone steriod injections has improved
432451 - swallowing, and thereby reduced vomitting problems caused
432452 - by achalasia. ref SDS C2 EZ4J
432454 - ..
432455 - There have been several occassions while hiking 11 miles that stomach
432456 - disorder occurs. Continuing the hike releives the problem.
432458 - ..
432459 - In recent weeks saliva tends to build up in the esophagus, so this is
432460 - a good time to do another dilation with triamcinolone steriod
432461 - injections, which resists contraction of LESV, so that effective
432462 - swallowing is maintained much longer than without injecting steriods,
432463 - as shown in Progress Notes on 111115 1300. ref SDS 81 AW6J and
432464 - reported again in Progress Notes on 120925 0900. ref SDS 86 E558
432466 - ..
432467 - Estimated LESV will engage below 16mm today, showing increased
432468 - shrinkage than prior procedures the past year.
432469 -
432470 - [...below on 141107 0800 at 1130 after the procedure Doctor
432471 - Lee reported LESV 15 mm, was more than twice the
432472 - contraction of prior procedures over the past 2 years.
432473 - ref SDS 0 6P6G
432475 - ..
432476 - Signed consent for the procedure, which is not visible - there is
432477 - merely a back screen to sign.
432479 - ..
432480 - Discussed request in the letter on 141103, for consideration to
432481 - schedule next meeting in 4 months, since swallowing and vomitting
432482 - problems have been severe this past cycle. ref SDS B9 3U66
432483 -
432484 -
432485 -
432486 -
432488 - ..
4325 -
4326 -
4327 - 1040
4328 -
432801 - OR EGD Dilation with Application Lidocaine
432802 - EGD Dilation Procedure in OR Application Lidocaine
432803 -
432804 - Follow up ref SDS B1 7V6I, ref SDS A5 CX4G.
432805 -
432806 - Doctor Lee and Denise wheeled the gurney into the OR for the
432807 - procedure. Met Brianna.
432809 - ..
432810 - Think the other nurse in the OR was Chris or Christine. Everything
432811 - went smoothly, as always.
432813 - ..
432814 - Conscious sedation was applied using the catheter set in Preparation,
432815 - per above. ref SDS 0 544G
432817 - ..
432818 - The team then did the EDG/dilation procedure.
432819 -
432820 -
432821 -
432823 - ..
4329 -
4330 -
4331 - 1130
4332 -
433201 - LESV Contracted 15 MM Dilated 18 MM Meeting Doctor Lee
433202 - Meeting Doctor Lee LESV Contracted 15 MM Dilated 18 MM
433203 -
433204 - Follow up ref SDS B9 5H5J, ref SDS B1 5H5J.
433206 - ..
433207 - An hour or so after the procedure, met with Doctor Lee in the recovery
433208 - room.
433210 - ..
433211 - Doctor Lee advised that LESV contracted 3 mm from 18 mm down to 15 mm,
433212 - since prior dilation 6 months ago on 140509 0900, ref SDS B1 5H5J;
433213 - following up discussion this morning prior to the procedure.
433214 - ref SDS 0 MQ4M This is 100% more than the 1.5 mm contraction from 18
433215 - mm, down to 16.5 mm reported for the prior cycle. It indicates the
433216 - experiment omitting triamcinolone steroid injection during the prior
433217 - procedure on 140509, explained earlier this morning, above,
433218 - ref SDS 0 4U8I, shows injections are still needed.
433220 - ..
433221 - Doctor Lee further advised that triamcinolone steriod was injected
433222 - today, in order to restore and maintain improved swallowing for the
433223 - next 6 months, as it has the past 2 years, since 120925...
433224 -
433225 - [On 150116 0813 at 0922 Doctor Lee called and left
433226 - voicemail message - pleased hearing that returning to
433227 - adding triamcinolone steriod injections has improved
433228 - swallowing, and thereby reduced vomitting problems caused
433229 - by achalasia. ref SDS C2 EZ4J
433230 -
433231 - LESV Dilated
433232 - Date from - to
433233 - 141107 15 18.....triamcinolone.......... ref SDS 0 I167
433234 - 140509 16.5 18............................ ref SDS B1 P680
433235 - 131115 16.5 18.....triamcinolone.......... ref SDS A5 RZ45
433236 - 130416 18 18.....triamcinolone.......... ref SDS 99 Y850
433237 - 130110 15 18.....triamcinolone.......... ref SDS 94 Q333
433238 - 120925 15 18.....triamcinolone.......... ref SDS 86 XB51
433239 - 120322 16.5 18............................ ref SDS 83 516N
433240 - 111115 16.5 18............................ ref SDS 81 IR57
433241 - 110819 15 16.5...triamcinolone.......... ref SDS 80 J978
433242 - 110429 13 16.5...triamcinolone.......... ref SDS 75 U23I
433243 - 110218 11 14.....triamcinolone.......... ref SDS 71 AA5O
433244 - 101210 11 14............................ ref SDS 67 H347
433245 - 100827 11 15............................ ref SDS 55 JE6X
433246 - 100305 11 15............................ ref SDS 48 WR6L
433248 - ..
433249 - Doctor Lee decided that since injection of triamcinolone steriod has
433250 - worked well to aid swallowing and avoid vomitting problems during
433251 - prior cycles, the next EGD dilation can be scheduled for another 6
433252 - months rather than in 4 months, discussed earlier today, per above.
433253 - ref SDS 0 7V5O
433254 -
433255 - [On 150319 0800 meeting with Doctor Lee indicated acid
433256 - reflux increased causing ulceration and constriction to
433257 - LESV that hampers swallowing, because fundoplication has
433258 - unraveled, ref SDS C4 N535; remedy - referral to Doctor
433259 - Stewart to assess re-fundoplication or other measures.
433260 - ref SDS C4 JQ5J
433262 - ..
433263 - We discussed scheduling next EGD dilation in 4 months, based on
433264 - difficulties this past cycle, with LESV contracting to 15 mm causing
433265 - swallowing difficulties. Doctor Lee indicated that if swallowing
433266 - becomes difficult sooner than 6 months, to let him know for scheduling
433267 - earlier EGD dilation procedure.
433269 - ..
433270 - Background on triamcinolone injection is further reviewed in the
433271 - record for the meeting at the VA on 140509 0900. ref SDS B1 R26H
433272 -
433273 -
433274 -
433275 -
433276 -
4333 -
SUBJECTS
Medical Chart Progress Notes VA EGD Procedure Stricture Lower Esopha
6403 -
640401 - ..
640402 - Progress Notes EGD Dilation Today
640403 -
640404 - Follow up ref SDS B1 CY7I, ref SDS A5 CY7I.
640405 -
640406 - After meeting with Doctor Lee in EDG Clinic, went to ROI and
640407 - requested CD with Doctor Lee's Progress Notes.
640409 - ..
640410 - VA website is at...
640411 -
640412 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
640413 -
640460 - 1. LOCAL TITLE: EGD 60111
640461 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
640462 - DATE OF NOTE: NOV 07, 2014@08:00 ENTRY DATE: FEB 19, 2015@12:44:20
640463 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
640464 - URGENCY: STATUS: COMPL
640465 -
640466 - [On 141125 0942 letter to the VA notifies Doctor Lee that
640467 - Progress Notes sometimes fail to post to patient medical
640468 - records on VA computer system, when the file includes an
640469 - addendum. ref SDS C0 GN75
640471 - ..
640472 - [On 150115 1110 visited VA Medical Center in Sacramento and
640473 - met with Jessica, an admin attendant for GI Clinic; she
640474 - could not find Progress Notes for EGD dilation procedure on
640475 - 141107, in patient medical records on the VA computer
640476 - system; she will notify Doctor Lee and discuss with
640477 - supervising nurse to expedite filing the Progress Notes
640478 - required by VA regulations for completing patient care.
640479 - ref SDS C1 MX5I
640481 - ..
640482 - 2. PATIENT NAME:
640489 - ..
640490 - 3. NAME OF PROCEDURES:
640491 -
640492 - 1. Esophagogastroduodenoscopy.
640493 - 2. Endoscopic biopsy.
640494 - 3. TTS balloon dilation of esophagus.
640496 - ..
640497 - 4. ATTENDING PHYSICIAN:
640498 - Randall E. Lee, M.D.
640500 - ..
640501 - 5. INDICATIONS:
640504 -
640505 - 1. 69-year-old man with a history of achalasia. After
640506 - undergoing coronary artery bypass and graft, he then
640507 - underwent laparoscopic myotomy and fundoplication at the
640508 - San Francisco VA Medical Center. He subsequently developed
640509 - acid reflux complicated by a recurrent distal esophageal
640510 - stricture.
640512 - ..
640513 - 2. His last EGD was May 2014 at which time he had a mild
640514 - esophageal stricture with an associated ulceration. This
640515 - was dilated sequentially from 15 mm to 18 mm. Biopsies
640516 - showed chronic inflammation, but no evidence of Barrett's
640517 - esophagus.
640519 - ..
640520 - 3. He is now here for a reevaluation and treatment. He was
640521 - recently seen by his cardiologist who thought that his
640522 - coronary artery disease was stable and asymptomatic.
640524 - ..
640525 - 4. He is noted to have an asymptomatic unconjugated
640526 - hyperbilirubinemia, which is consistent with Gilbert's
640527 - syndrome.
640529 - ..
640530 - 6. CONSENT:
640531 -
640532 - The risks, benefits, and alternatives to this procedure
640533 - including but not limited to the risks of bleeding and bowel
640534 - perforation were explained to the patient. The patient
640535 - understood and provided a written informed consent.
640537 - ..
640538 - 7. INTRAVENOUS MEDICATION:
640539 -
640540 - 1. Diphenhydramine 50 mg.
640541 - 2. Fentanyl 150 mcg.
640542 - 3. Midazolam 5 mg.
640544 - ..
640545 - Why was Fentanyl 150 mcg reduced from 200 mcg for prior procedure on
640546 - 140509? ref SDS B1 P341
640548 - ..
640549 - Progress Notes EGD Dilation procedure on 141107 continues...
640550 -
640551 - 8. PROCEDURE:
640552 -
640553 - 1. In the Sacramento VA GI Endoscopy Unit, the patient was
640554 - placed in the left lateral decubitus position.
640556 - ..
640557 - 2. Oxygen at 2 liters per minute by nasal cannula was administered.
640559 - ..
640560 - 3. Continuous oximetric and hemodynamic monitoring was initiated.
640562 - ..
640563 - 4. Intravenous sedation was administered in divided doses.
640565 - ..
640566 - 5. After a bite block was placed in the patient's mouth, an
640567 - Olympus GIF-H180J video gastroscope was advanced under
640568 - direct vision [...into the...] esophagus.
640570 - ..
640571 - 6. The GE junction was noted at about 39 cm and there was an
640572 - associated shallow ulceration and esophageal narrowing.
640573 - This did not impede passage of the diagnostic endoscope.
640575 - ..
640576 - 7. The endoscope was advanced into the descending duodenum,
640577 - then retroflexed views of the incisura, cardia, and fundus
640578 - were performed.
640580 - ..
640581 - Photographs of esophagus and stomach for procedure on 141107...
640592 - ..
640593 - 8. Biopsies were taken of the ulcerated area at the GE
640594 - junction at 39 cm labeled A and from a few whitish
640595 - chalk-like deposits in the mid esophageal body at 39 cm
640596 - labeled B.
640597 -
640598 - [On 150319 0800 meeting with Doctor Lee indicated acid
640599 - reflux increased causing ulceration and constriction to
640600 - LESV that hampers swallowing, because fundoplication has
640601 - unraveled, ref SDS C4 N535; remedy - referral to Doctor
640602 - Stewart to assess re-fundoplication or other measures.
640603 - ref SDS C4 JQ5J
640605 - ..
640606 - [On 150319 0800 meeting Doctor Lee reports hiatal hernia
640607 - reflects failure fundoplication that causes increased acid
640608 - burn on LESV leading to ulceration; this condition
640609 - increases stricture that in turn increases swallowing
640610 - problems, despite increased Omeprazole medication.
640611 - ref SDS C5 N535
640613 - ..
640614 - 9. Subsequently, a TTS balloon dilator was advanced across the
640615 - distal esophagus and inflated sequentially from 15 to 16.5
640616 - to 18 mm. As visualized through the balloon, there was
640617 - minimal contact with the mucosa at 16.5 mm and a small
640618 - amount of mucosal tearing at 18 mm.
640619 -
640620 - LESV Dilated
640621 - Date from - to
640622 - 141107 15 18.....triamcinolone..4.0mL..... ref SDS 0 I167
640623 - 140509 16.5 18.............................. ref SDS B1 P680
640624 - 131115 16.5 18.....triamcinolone..2.0mL..... ref SDS A5 RZ45
640625 - 130416 18 18.....triamcinolone..2.0mL..... ref SDS 99 Y850
640626 - 130110 15 18.....triamcinolone..3.0mL..... ref SDS 94 Q333
640627 - 120925 15 18.....triamcinolone..4.0mL..... ref SDS 86 XB51
640628 - 120322 16.5 18.............................. ref SDS 83 516N
640629 - 111115 16.5 18.............................. ref SDS 81 IR57
640630 - 110819 15 16.5...triamcinolone..2.5mL..... ref SDS 80 J978
640631 - 110429 13 16.5...triamcinolone..3.5mL..... ref SDS 75 U23I
640632 - 110218 11 14.....triamcinolone..2.0mL..... ref SDS 71 AA5O
640633 - 101210 11 14.............................. ref SDS 67 H347
640634 - 100827 11 15.............................. ref SDS 55 JE6X
640635 - 100305 11 15.............................. ref SDS 48 WR6L
640637 - ..
640638 - Reporting "minimal contact with the mucosa at 16.5 mm" conflicts with
640639 - understandings from post procedure meeting advising LESV contracted to
640640 - 15 mm, ref SDS 0 5H5J, consistent with the record of swallowing
640641 - problems from omitting triamcinolone steroid injection for prior EGD
640642 - dilation on 140509...
640644 - ..
640645 - 1. On 140718 1017 called Doctor Lee's nurse, Lapria; she
640646 - will notify Doctor Lee to call about advancing next EGD
640647 - dilation to resolve swallowing problems shown by
640648 - increased vomitting. ref SDS B4 PH53
640650 - ..
640651 - 2. On 140810 1839 letter to Doctor Lee requesting EGD
640652 - dilation with triamcinolone injection soonest, if
640653 - cancellation occurs; but, not an emergency, ref SDS B5
640654 - W83K, based on history rising vomitting swallowing
640655 - problems, shown in patient history case study on
640656 - 120101, beginning 140712. ref SDS 82 4E4M
640658 - ..
640659 - 3. On 140819 0800 during meeting at VA Primary Care Clinic
640660 - in Martinez, Doctor Sandhu indicated Doctor Lee at VA
640661 - Medical Center in Sacramento will be notified about
640662 - rising achalasia symptoms for consideration to advance
640663 - EGD dilation procedure. ref SDS B7 EX78
640665 - ..
640666 - Progress Notes EGD Dilation procedure on 141107 continues...
640668 - ..
640669 - 10. Triamcinolone was injected into the esophageal stricture
640670 - site after dilation. This was at a dose of 40/mL for a
640671 - total dose of approximately 4 mL.
640673 - ..
640674 - Previously on 120925, Triamcinolone of 1mL was injected into each of 4
640675 - LESV quadrants, to comprise 4mL total injection. 120925 0900,
640676 - ref SDS 86 R87N
640678 - ..
640679 - Progress Notes EGD Dilation procedure on 141107 continues...
640680 -
640681 - 11. The stomach was decompressed and the gastroscope removed.
640683 - ..
640684 - 9. COMPLICATIONS:
640685 -
640686 - None.
640688 - ..
640689 - Ulceration LESV and Hiatal Hernia New Findings Fundoplication Failed
640690 -
640691 - Follow up ref SDS B1 P396.
640692 -
640693 - 10. FINDINGS:
640694 -
640695 - 1. Previous area of esophageal stricture noted again at 39 cm.
640696 - Probable starting diameter was approximately 16.5 mm that
640697 - was then dilated to 18 mm.
640699 - ..
640700 - "Probable starting diameter was approximately 16.5 mm" appears
640701 - conflicting with record omitting triamcinolone injection and onset of
640702 - swallowing problems within a few months after prior EGD dilation on
640703 - 140509, per comment above. ref SDS 0 T55I
640705 - ..
640706 - Progress Notes EGD Dilation procedure on 141107 continues...
640707 -
640708 - 2. Shallow ulceration at the GE junction previously shown to
640709 - be just chronic inflammation again rebiopsied.
640710 -
640711 - [On 150421 1210 next EGD dilation found ulcerations
640712 - regressing (improving) to mere erosions. ref SDS C6 PXXY
640714 - ..
640715 - 3. Gastric fundus surgically altered consistent with known
640716 - history of fundoplication.
640718 - ..
640719 - 4. Hiatal hernia noted.
640721 - ..
640722 - On 140509 0900 Progress Notes report Hiatal hernia, ref SDS B1 P34O;
640723 - this was not reported for prior procedure on 131115 0700. ref SDS A5
640724 - PY6O At that time on 140509, Progress Notes further state "...hiatal
640725 - hernia suggests the fundoplication appears to be loosening."
640726 - ref SDS B1 I93F
640728 - ..
640729 - Photograph #4 showing fundoplication from procedure today...
640730 -
640733 - ...seems to show marked difference with photograph from EGD dilation
640734 - procedure on 131115, when Progress Notes fundoplication remains
640735 - intack. ref SDS A5 JW4I
640739 - ..
640740 - Fundoplication on 131115 appears much more wrinkled, as expected for
640741 - "wrapped" tissue; fundoplication in the photograph today appears much
640742 - flatter and smoother, suggesting loosening of fundoplication, as set
640743 - out in Progress Notes on 140509. ref SDS B1 I93F
640744 -
640745 - [On 150319 0800 meeting with Doctor Lee indicated acid
640746 - reflux increased causing ulceration that increases
640747 - constriction to LESV that hampers swallowing, because
640748 - fundoplication has unraveled, i.e., failed, further
640749 - causing hiatal hernia, ref SDS C4 N535; remedy -
640750 - referral to Doctor Stewart to assess re-fundoplication
640751 - or other measures. ref SDS C4 JQ5J
640753 - ..
640754 - Progress Notes continue...
640755 -
640756 - 5. Normal pylorus.
640758 - ..
640759 - 6. Normal duodenum to D2.
640761 - ..
640762 - 7. Scattered white deposits without surrounding erythema in
640763 - the esophageal body.
640765 - ..
640766 - 11. IMPRESSION:
640767 -
640768 - 1. Gastroesophageal reflux stricture with minor recurrence
640769 - since prior examination in May 2014. The presence of the
640770 - shallow ulceration suggests continued need for proton pump
640771 - inhibitor therapy.
640773 - ..
640774 - On 140801 in case study on 120101, Omeprazole not delivered; implement
640775 - fasting regimen to increase immunity and lower weight, ref SDS 82
640776 - NW6I; aligns with prior delays getting Omeprazole refill issued by VA
640777 - on 140725, reported on 140715 1614, ref SDS B2 4O6H, and prescribed on
640778 - 140509, to take 2 pills a day for achalasia - relieve acid burn that
640779 - inflames LESV, ref SDS B1 JG4K, confirmed Progress Notes. ref SDS B1
640780 - P43G Call to VA on 140718 to expedite delivery asked if necessary to
640781 - continue taking pills when supply runs out. ref SDS B3 U76M
640783 - ..
640784 - Progress Notes EGD Dilation procedure on 141107 continues...
640785 -
640786 - 2. Proton pump inhibitor therapy also continues to be
640787 - necessary to reduce esophageal stricture reformation.
640788 -
640789 - [On 150319 0800 meeting with Doctor Lee indicated acid
640790 - reflux increased causing ulceration and constriction to
640791 - LESV that hampers swallowing, because fundoplication has
640792 - unraveled, ref SDS C4 N535; remedy - referral to Doctor
640793 - Stewart to assess re-fundoplication or other measures.
640794 - ref SDS C4 JQ5J
640796 - ..
640797 - 3. Scattered plaques in the esophageal body consistent with
640798 - candidiasis as a result of the esophageal stasis.
640800 - ..
640801 - For some reason there is no report of fundoplication loosening or
640802 - unravelling as found and previously associated with hiatal hernia
640803 - reported in the EGD dilation procedure on 140509 0900. ref SDS B1 I93F
640805 - ..
640806 - 12. RECOMMENDATIONS:
640807 -
640808 - 1. Await the pathology results.
640809 -
640810 - 2. Continue omeprazole 20 mg twice daily.
640812 - ..
640813 - 3. Repeat EGD and dilation in approximately 6 months.
640814 -
640815 - [On 150319 0800 meeting with Doctor Lee indicated acid
640816 - reflux increased causing ulceration and constriction to
640817 - LESV that hampers swallowing, because fundoplication has
640818 - unraveled, i.e., failed, ref SDS C4 N535; remedy -
640819 - referral to Doctor Stewart to assess re-fundoplication
640820 - or other measures. ref SDS C4 JQ5J
640822 - ..
640823 - 13. DISPOSITION:
640824 -
640825 - 1. The patient was observed in the Recovery Room then
640826 - discharged to home with a companion.
640827 -
640828 - 2. I reviewed the endoscopic findings with the patient prior
640829 - to discharge.
640831 - ..
640832 - 14. TIME START: 0856 hours.
640833 - TIME END: 0917 hours.
640835 - ..
640836 - 15. LRM/CMTS
640837 - $end:
640839 - ..
640840 - Biopsy Reports No Barrett's Esophabus Precursor to Cancer
640841 -
640842 - Follow up ref SDS B9 1B5F, ref SDS B1 1B5F.
640843 -
640844 - 16. Microscopic exam/diagnosis: (Date Spec taken: Nov 07, 2014)
640845 -
640846 - A. GASTROESOPHAGEAL JUNCTION, 39CM (BIOPSY):
640847 -
640848 - - HYPERPLASTIC REACTIVE SQUAMOUS MUCOSA WITH ACUTE
640849 - INFLAMMATION
640850 -
640851 - - PAS-F IS NEGATIVE FOR FUNGAL ELEMENTS
640853 - ..
640854 - B. ESOPHAGUS, 29CM (BIOPSY):
640855 -
640856 - - HYPERPLASTIC REACTIVE SQUAMOUS MUCOSA WITH ACUTE AND
640857 - CHRONIC INFLAMMATION
640858 -
640859 - - PAS-F IS POSITIVE FOR FUNGAL ELEMENTS, CONSISTENT WITH
640860 - CANDIDA
640861 -
640863 - ..
640864 - Doctor Lee Letter Report Results EGD Dilation 140509
640865 -
640866 - Follow up ref SDS B9 N57M, ref SDS B1 N57M.
640867 -
640868 - Doctor Lee's post-procedure letter received on 150324, and incoporated
640869 - into Progress Notes, says...
640871 - ..
640872 - 1. In Reply Refer To: Sacramento VA
640873 - Gastroenterology (111/SMAT)
640880 -
640881 - 2. 18 March 2015
640885 - ..
640886 - 3. You had an endoscopic examination of your esophagus, stomach,
640887 - and upper intestine (EGD) at the Sacramento VAMC on 7 November
640888 - 2014. I am happy to report to you that the biopsies showed NO
640889 - cancer.
640891 - ..
640892 - 4. There was inflammation (irritation) from food and liquid
640893 - remaining in the esophagus after you swallow. We will discuss
640894 - some strategies to resolve this at our next visit.
640896 - ..
640897 - 5. Truly yours,
640899 - ..
640900 - 6. Randall E. Lee, MD, FACP
640901 - Gastroenterologist, VA NCHCS
640902 - 916-366-5339
640903 -
640904 - 7. /es/ Randall E. Lee, MD
640905 - Staff Physician, Gastroenterology
640906 - Signed: 03/18/2015 15:52
640907 -
640908 -
640909 -
640910 -
640911 -
640912 -
640913 -
640914 -
640915 -
640916 -
640917 -
640918 -
640919 -
640920 -