CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 16.
2103 -
2103 - ..
2104 - Summary/Objective
2105 -
210501 - Follow up ref SDS C1 0000. ref SDS B2 0000.
210502 -
210503 - Met with Doctor Lee at VA Medical Center in Sacramento (Mather).
210504 - Checking in and initial administration went well. ref SDS 0 GD4H
210505 - Preparation for the procedure was professional; fortunately there were
210506 - no difficulties setting IV for conscious sedation today. ref SDS 0
210507 - 5W5I Reported pain level 2 right knee MCL. ref SDS 0 LO9K Doctor Lee
210508 - advised referral to San Francisco will be filed after EDG dilation
210509 - procedure today, to evaluate loosening fundoplication. ref SDS 0 DZ4I
210510 - Patient reported difficulty swallowing this cycle did not occur until
210511 - 4 weeks or so, because triamcinalone steriod was injected during prior
210512 - procedure on 141107, ref SDS 0 P55L, and shown by EGD dilation LESV
210513 - from 16.5 mm back to 18 mm. ref SDS 0 HU42 Progress Notes report
210514 - findings of hiatal hernia. ref SDS 0 QD6O Impression today that
210515 - ulceration has subsided to mere errosions seems promising. ref SDS 0
210516 - PXXY
210518 - ..
210519 - [On 150514 0130 letter to Doctor Lee requests file Progress
210520 - Notes for EGD Dilation today, and make referral to Doctor
210521 - Stewart, to prepare for meeting with Doctor Lee scheduled
210522 - on 150521. ref SDS D0 K37G
210524 - ..
210525 - [On 150521 0800 meeting with Doctor Lee at VAMC in
210526 - Sacramento - concensus uncharacteristic vomitting after
210527 - recent EGD dilation procedure on 150421, due to patient not
210528 - eating slowly with small bites and drinking liquids
210529 - frequently, especially when eating meat products that have
210530 - high viscocity with esophageal tissue, and so tends to
210531 - stick, causing vomitting. ref SDS D2 WT9L
210533 - ..
210534 - [On 150925 0336 VA scheduled next meeting for EGD dilation
210535 - on 151204 0800, 8 months since prior meeting today on
210536 - 150421. ref SDS D4 SR6L
210537 -
210538 -
210539 -
210540 -
210542 - ..
2106 -
2107 -
2108 - Background
2109 -
210901 - On 050629 meeting Primary Care swallowing and vomitting problems
210902 - reported. ref SDS 1 K78K
210904 - ..
210905 - On 050714 barrium swallow test, ref SDS 2 2I4S, showed esophagus
210906 - distorted by swallowing problems. ref SDS 2 WE4H
210908 - ..
210909 - On 050816 meeting Primary Care Doctor Sandhu diagnoses achalasia.
210910 - ref SDS 3 DG8G Ultrasound test ordered to verify initial diagnosis of
210911 - swallowing and vomitting problems. ref SDS 3 6E7H Primary Care made
210912 - referral to GI clinic for care to resolve swallowing problems.
210913 - ref SDS 3 0G7M
210915 - ..
210916 - On 050830 ultrasound test evaluate swallowing problems possible
210917 - diagnosis achalasia. ref SDS 4 DG8G
210919 - ..
210920 - On 050830 results received barrium swallow test performed on 050714,
210921 - findings in the lower espohagus and gastroesophageal junction are
210922 - consistent with achalasia - recommend endoscopic examination.
210923 - ref SDS 4 6H9S
210925 - ..
210926 - On 050906 report ultrasound test on 050830, finds no cause for
210927 - swallowing problems and does not diagnose achalasia. ref SDS 5 BM6R
210929 - ..
210930 - On 051202 meeting GI Clinic Doctor Lee diagnoses achalasia.
210931 - ref SDS 6 HP9H Orders endoscopy (EGD) test to verify diagnosis of
210932 - achalasia and assess for cancer. ref SDS 6 NZ5H
210934 - ..
210935 - On 051209 GI Clinic endoscopy examination preliminary findings no
210936 - evidence of cancer, ref SDS 7 0001; biopsy report should be submitted
210937 - in a few weeks to confirm status of cancer, ref SDS 7 PY5J, and if so,
210938 - then a procedure can be schedule for next month to dilate the
210939 - exophageal sphincter valve. ref SDS 7 NZ5H
210941 - ..
210942 - On 051222 biopsy reports no evidence of cancer. ref SDS 8 FT6M
210944 - ..
210945 - On 060111 received letter from Doctor Lee in the Gastrointestinal (GI)
210946 - Clinic reporting that the biopsy was negative for cancer and
210947 - infection; next step is manometry test to verify achalasia, then
210948 - treatment for achalasia. ref SDS 9 4Q3R
210950 - ..
210951 - On 060125 manomety test scheduled for 060209 0800. ref SDS 10 GG9I
210953 - ..
210954 - On 060209 meeting at VA Mather AFB in Sacramento, test was postponed
210955 - until 060223, due to equipment failure. ref SDS 11 OW6M
210957 - ..
210958 - On 060221 Jimmy in GI Department at Sacramento VA Medical Center
210959 - reports manometry equipment still broken; has been sent out for
210960 - repairs and there is no date at this time on when the equipment will
210961 - be available for use at the VA. ref SDS 12 ND7M
210963 - ..
210964 - On 060330 endoscopy follow up examination at GI Department Sacramento
210965 - Medical Center - Doctor Lee finds no evidence cancer performed at VA
210966 - Sacramento condition precedent treatment recover from achalasia.
210967 - ref SDS 13 VX4G
210969 - ..
210970 - On 060330 manometry test performed by Doctor Lee at VA in Sacramento,
210971 - ref SDS 13 MC7P, verifies diagnosis swallowing and vomitting problems
210972 - caused by achalasia, ref SDS 13 MD4N, patient meets criteria for
210973 - treatment with pneumatic dilation. ref SDS 13 MD5G
210975 - ..
210976 - On 060505 Martinez VA GI clinic Doctor Lee reported equipment and
210977 - pneumatic balloon materials on hand to perform dilation for treating
210978 - achalasia; treatment delayed until diagnostic data is received from
210979 - Sacramento VA Medical Center from manometry test performed on 060330;
210980 - doctor following up to obtain data; will submit test data to patient
210981 - during the week of 060508, along with a schedule to treat achalasia.
210982 - ref SDS 14 FT6M
210984 - ..
210985 - On 060614 Martinez VA GI clinic reports increased work load treating
210986 - soldiers returning from war in Iraq requires prioritizing; patient
210987 - advocate, Rubin Soto, will coordinate with the GI Clinic notifying the
210988 - customer of the schedule based on current priorities. ref SDS 15 J86N
210990 - ..
210991 - On 070220 letter to VA asks about progress getting test results from
210992 - VA in Sacramento, and scheduling surgery for achalasia, ref SDS 16
210993 - 5R5R
210995 - ..
210996 - On 090812 1030 continued vomitting achalasia causes weight loss 30
210997 - pounds in a few months, Primary Care physician notified GI clinic to
210998 - review schedule for dilation to relieve achalasia. ref SDS 17 7L5O
211000 - ..
211001 - On 090908 meeting GI Clinic in Martinez reports treatment for
211002 - achalasia still waiting to receive results for manometry test on
211003 - 060330, at Sacramento VA Medical Center. ref SDS 18 HX46 Prepared new
211004 - work plan to treat achalasia without manometry test results, because
211005 - the doctor performed the test 3 years ago, and is so knows results
211006 - consistent with achalasia, shown on 060330 0712, ref SDS 13 MD4N;
211007 - schedules treatment for achalasia after treadmill stress test,
211008 - ref SDS 18 BU6W, to evaluate new chest pains hiking hills at Lafayette
211009 - Reservoir which have not occurred doing extended exercise hiking 3 -
211010 - 14 miles a day over the past 5 years. ref SDS 18 MY4N
211012 - ..
211013 - On 091021 report history achalasia issue during meeting with
211014 - cardiothoracic surgery team to prepare for heart bypass surgery the
211015 - next day. ref SDS 20 NX6M Surgery team will coordinate with
211016 - anesthesia team to provide swallowing relief during heart surgery to
211017 - prevent choking. ref SDS 20 R78O
211019 - ..
211020 - On 091022 0700 meeting anesthesia team - Doctor Brezinski not familiar
211021 - with achalasia - asked if achalasia has been reported to the VA?
211022 - ref SDS 21 JF9K While being prepared with IVs for surgery, patient
211023 - assists anesthesia find VA records on achalasia, ref SDS 21 2W4K;
211024 - Doctor Brezenski makes plans for patient care and safety so that
211025 - achalasia does not risk death during heart surgery. ref SDS 21 GX4J
211027 - ..
211028 - On 091022 cabg x4 cardiothoracic surgery San Francisco Medical Center.
211029 - ref SDS 21 PQWU
211031 - ..
211032 - On 091030 0800 at 1406 meeting with Doctor Stewart at San Francisco
211033 - Medical Center during recovery from heart surgery, proposes Heller
211034 - Myotomy surgery rather than pneumatic (balloon) dilation as more
211035 - effective and longer lasting solution to recover from swallowing and
211036 - vomitting problems caused by achalasia. ref SDS 24 KE3B
211038 - ..
211039 - On 091030 0800 at 1430 received documentation from GI Department at
211040 - San Francisco Medical Center - review shows 3 different treatments for
211041 - achalasia - pills, pneumatic dilation, Heller Myotomy surgery.
211042 - ref SDS 24 495I
211044 - ..
211045 - On 091030 0800 at 1440 meeting cardiothoracic surgery team; Doctor
211046 - Ratcliff concerned about how to maintain nutrition for the patient to
211047 - recover from heart surgery while digestion remains problematic due to
211048 - achalasia; proposes feeding tube for several months until Heller
211049 - Myotomy surgery. ref SDS 24 03GF
211051 - ..
211052 - On 091216 Heller Myotomy surgery at San Francisco VA Medical Center to
211053 - recover from achalasia. 091216 0600, ref SDS 36 KE9U
211055 - ..
211056 - On 100202 meeting with Doctor Lee - report swallowing and vomitting
211057 - problems 3 months after Heller Myotomy surgery. Doctor explains
211058 - achalasia disease breaks nerve connections from the brain that
211059 - contract the esophagus to force food and liquid from the mouth through
211060 - the esophagus; as well broken nerve connections prevent the lower
211061 - esophageal sphincter valve (LESV) to relax so that content can pass
211062 - into the stomach. Without esophageal contractions, food and liquid
211063 - can only reach the stomach with gravity, but since the LESV won't
211064 - relax the patient continues to have swallowing and vomitting problems,
211065 - despite Heller Myotomy surgery on 091216, intended to maintain
211066 - adequate opening into the stomach. ref SDS 47 485W
211068 - ..
211069 - On 100305 meeting at GI Clinic in Martinez, EGD procedure dilated LESV
211070 - from 11 to 15 mm. ref SDS 48 WR6L
211072 - ..
211073 - On 100827 meeting at GI Clinic in Martinez, EGD procedure dilated LESV
211074 - from 11 to 15 mm. ref SDS 55 JE6X
211076 - ..
211077 - On 101210 EGD procedure dilated esophageal sphincter valve (LESV)
211078 - without sedation, ref SDS 67 BE7K - dilated LESV again from 11 to 14
211079 - mm. ref SDS 67 BF6L
211081 - ..
211082 - On 101216 1021 letter commends medical team for excellent work, and
211083 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
211085 - ..
211086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using
211087 - anesthesia with Fentanyl. ref SDS 71 PQWY LESV dilated 11 - 14 mm,
211088 - and added triamcinolone steriod injections to resist contraction of
211089 - LESV so that swallowing is maintained over the next 3 month cycle.
211090 - ref SDS 71 SR4G
211092 - ..
211093 - On 110429 0830 5th EGD dilation at VA in Martinez - triamcinolone
211094 - steriod injections worked well to resist contraction of LESV so that
211095 - swallowing was maintained over the prior 3 month cycle, ref SDS 75
211096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 75 U23I, and
211097 - triamcinolone injections were continued. ref SDS 75 SS5N
211099 - ..
211100 - On 110607 1414 visited GI Department, ref SDS 77 HC5H, and Charlene
211101 - reported a computer mistakes requires scheduling next EGD dilation on
211102 - 110819 0830. ref SDS 77 N642 Requested meeting with Doctor Lee to
211103 - review pending action items. ref SDS 77 4P6J,
211105 - ..
211106 - On 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter
211107 - valve. Triamcinolone steriod injections worked well to resist
211108 - contraction of LESV so that swallowing is maintained over the prior 3
211109 - month cycle, so LESV dilated from 15 - 16.5 mm, ref SDS 80 J978, and
211110 - triamcinolone injections were continued. ref SDS 80 J985
211112 - ..
211113 - On 111115 1300 EGD dilation procedure - triamcinolone steriod injections
211114 - worked well over the prior 3 month cycle, so LESV dilated from 16.5 -
211115 - 18 mm, ref SDS 81 IR57; for some reason triamcinolone injections to
211116 - resist contraction of LESV was not performed. ref SDS 81 IS6L
211118 - ..
211119 - On 120322 1030 EGD dilation procedure - swallowing and vomitting problems
211120 - increased without triamcinolone steriod injections on prior 3 month
211121 - cycle. ref SDS 83 UI9H LESV dilated from 16.5 - 18 mm. ref SDS 83
211122 - 516N Triamcinolone injections to resist contraction of LESV was not
211123 - performed. ref SDS 83 5179
211125 - ..
211126 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA
211127 - business unit; reported patient history. ref SDS 86 RG9K Scheduled
211128 - EGD and dilation procedure for 1300; returned and performed procedure,
211129 - ref SDS 86 TB4J; dilated from 15 mm to 18 mm. ref SDS 86 XB51
211130 - Swallowing and vomitting problems increased after omitting
211131 - triamcinolone steriod injections to resist contraction of LESV after
211132 - dilation, ref SDS 86 TZ4M; therefore, injections were resumed to
211133 - complement dilation to enable and maintain effective swallowing.
211134 - ref SDS 86 R87N
211136 - ..
211137 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found
211138 - improvement recovering from acalasia, LESV contracted only slightly
211139 - from 18 mm down to 15 mm. ref SDS 94 Q333
211141 - ..
211142 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV
211143 - remained at 18 MM, ref SDS 99 CO5N, same as dialated 4 months earlier
211144 - on 130110 0900. ref SDS 94 Q333 Report CT test on 130117, shows
211145 - esophagus fully recovered from severe distortions caused by achalasia
211146 - 8 years earlier. ref SDS 99 MT6F Doctor Lee injected steriod again to
211147 - maintain swallowing. ref SDS 99 F38G Prescribed reducing Omeprazole
211148 - to 1 pill per day. ref SDS 99 R74M Scheduled next EDG dilation in 6
211149 - months, instead of 3. ref SDS 99 6P6G
211151 - ..
211152 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5
211153 - to 18 mm. ref SDS A5 CO5N Triamcinolone steriod injected again to
211154 - maintain improved swallowing. ref SDS A5 I167 Omeprazole medication
211155 - maintained 20 mg taken morning and evening for 1 month, then reduce to
211156 - 20 mg once per day. ref SDS A5 R74M Biopsies taken. ref SDS A5 3N8L
211158 - ..
211159 - On 131121 1604 ordered refill of Omeprazole to aid digestion. There
211160 - is 1 refill remaining. ref SDS A6 YS4O
211162 - ..
211163 - On 131205 1443 received order for Omeprazole prescription placed on
211164 - 131121. ref SDS A7 5N3O
211166 - ..
211167 - On 140318 1043 received letter cancelling meeting scheduled for
211168 - EGD/Dilation procedure on 140425 1000, ref SDS A9 935L; a second
211169 - letter scheduled prodedure on 140509 0900. ref SDS A9 5D7H
211171 - ..
211172 - On 140401 1659 ordered refill Omeprazole; none are remaining; need
211173 - Doctor Lee to order new prescription to increase refills. ref SDS B0
211174 - 4P5M
211176 - ..
211177 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical
211178 - center in Sacramento, Mather. ref SDS B2 K37G Pre-op preperation went
211179 - well - IV setup on first stick. ref SDS B2 EP75 Doctor ordered refills
211180 - for Omeprazole. ref SDS B2 AW5O Doctor patient partnership continues
211181 - to progress with doctor reading up on patient history to be prepared
211182 - for effective meeting. ref SDS B2 ZZ6J Doctor Lee recalled today
211183 - having made timely referral for having heart surgery, enabling patient
211184 - to recover and Half Dome 4 years later. ref SDS B2 0N6I Reported
211185 - swallowing and vomitting problems reduced past 6 months with
211186 - triamcinolone steriod injections to resist contraction of LESV.
211187 - ref SDS B2 VV6N Doctor Lee dilated LESV contracted to only 16.5 MM
211188 - over past 6 months with triamcinolone steriod injections to resist
211189 - contraction; he dilated LESV back to 18 MMy, ref SDS B2 5H5J, scheduled
211190 - next EGD dilation in 6 months since this worked well the past 6 months
211191 - with triamcinolone steriod injections. ref SDS B2 549I The doctor
211192 - explained that since there was no tearing of LESV during procedure
211193 - today, triamcinolone steriod was not injected into LESV to resist
211194 - contraction. ref SDS B2 I167 Progress notes report small tearing of
211195 - LESV during dilation procedure. ref SDS B2 P680
211197 - ..
211198 - On 140718 1017 planning for notifying VA to update current fill date
211199 - for Omeprazole. ref SDS B5 U88L Kathy visited VA in Sacramento, and
211200 - requested changing refill date for Omeprazole to 140718. ref SDS B5
211201 - OL5K VA representative called customer, and said Doctor Lee would
211202 - call back later that day to consider action on updating scheduled
211203 - refill date of Omeprazole to 140718. ref SDS B5 U76M
211205 - ..
211206 - On 140810 1839 letter to Doctor Lee requesting EGD dilation with
211207 - triamcinolone injection soonest, if cancellation occurs; but, not an
211208 - emergency, ref SDS B7 W83K, based on history rising vomitting
211209 - swallowing problems, shown in patient history case study on 120101,
211210 - beginning 140712. ref SDS 82 4E4M
211212 - ..
211213 - On 140819 0800 during meeting at VA Primary Care Clinic in Martinez,
211214 - Doctor Sandhu indicated Doctor Lee at VA Medical Center in Sacramento
211215 - will be notified about rising achalasia symptoms for consideration to
211216 - advance EGD dilation procedure. ref SDS B8 EX78
211218 - ..
211219 - On 141014 0943 Kathy visited VA Medical Center in Sacramento and met
211220 - with Lapria again, who advised that the VA responded in a letter on
211221 - 141001, to the letter on 140810, and further scheduled a meeting with
211222 - Doctor Lee on 141121 1530. ref SDS B9 QJ5N
211224 - ..
211225 - On 141103 2152 submitted agenda for meeting with Doctor Lee at VA
211226 - Sacramento Medical Center on 141107 0800, for next EGD dilation.
211227 - ref SDS C0 K37G Submit record showing normal swallowing occurs longer
211228 - with triamcinolone steriod injection to resist contraction of LESV.
211229 - ref SDS C0 3U97 Request schedule next EGD dilation in 4 months, and
211230 - if LESV does not contract, then schedule following EGD dilation in 6
211231 - months. ref SDS C0 3U66 Notified results of Half Dome hike.
211232 - ref SDS C0 3U6Y
211234 - ..
211235 - On 141107 0800 EGD dilation procedure - setting IV for conscious
211236 - sedation required 3 sticks. ref SDS C1 5W5I Meeting Doctor Lee guided
211237 - by agenda facilitated collaboration through doctor patient
211238 - partnership. ref SDS C1 VV6N Doctor explained increased difficulty
211239 - swallowing due to experiment omitting triamcinalone steriod injection
211240 - on prior procedure, ref SDS C1 4U8I, shown by LESV contracting back to
211241 - from 15 mm. ref SDS C1 T55I Progress Notes report finding ulceration
211242 - and hiatal hernia. ref SDS C1 MG6N Photographs seem to show
211243 - significantly different condition of fundoplication from a year
211244 - earlier. ref SDS C1 I74I
211246 - ..
211247 - On 150319 0800 meeting Doctor Lee in GI Clinic VA Medical Center
211248 - Sacramento report swallowing improved with triamcinalone steriod
211249 - injections on 141107 EGD dilation procedure. ref SDS C6 0M6I Doctor
211250 - Lee advised that increased orange juice consumption aids digestion,
211251 - and presents no health risks. ref SDS C6 YF5M Scheduled next EGD
211252 - dilation procedure on 150421 1300. ref SDS C6 PS4O Fundoplication
211253 - failure increases acid burn that caused ulceration with hiatal hernia
211254 - with increased recurrance achalasia. ref SDS C6 O56O Doctor Lee will
211255 - make referral to Doctor Stewart at General Surgery VA Medical Center
211256 - in San Francisco for consideration of "redo" fundaplicaiton.
211257 - ref SDS C6 JQ5J Doctor Lee completed Progress Notes for EGD dilation
211258 - on 141107. ref SDS C6 PS53 Doctor Lee will recommend Doctor Stewart
211259 - order CT test to evaluate recurrance achalasia due to failure
211260 - fundoplication. ref SDS C6 TH5M This test can include coronary CTA to
211261 - evaluate regression atherosclerosis. ref SDS C6 GB56
211263 - ..
211264 - On 150420 1752 submitted letter to Doctor Lee with agenda for meeting
211265 - the next day on 150421 1300 for EGD dilation. ref SDS C8 0M6I
211266 -
211267 -
211269 - ..
211270 - On 150514 0130 letter to Doctor Lee requests file Progress Notes for
211271 - EGD Dilation today, and make referral to Doctor Stewart, to prepare
211272 - for meeting with Doctor Lee scheduled on 150521. ref SDS D0 K37G
211274 - ..
211275 - On 150521 0800 meeting with Doctor Lee at VAMC in Sacramento -
211276 - concensus uncharacteristic vomitting after recent EGD dilation
211277 - procedure on 150421, due to patient not eating slowly with small bites
211278 - and drinking liquids frequently, especially when eating meat products
211279 - that have high viscocity with esophageal tissue, and so tends to
211280 - stick, causing vomitting. ref SDS D2 WT9L
211281 -
211282 -
211283 -
211284 -
211285 -
211286 -
211287 -
211289 - ..
2113 -
2114 -
2115 - Progress
211601 - ..
211602 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
211603 - GI Department VA Sacramento Medical Center Administration EGD Dilation
211604 -
211605 - Follow up ref SDS C1 NU8L, ref SDS C0 NU8L.
211606 -
211607 - Meeting today implements planning in Progress Notes on 141107 0800,
211608 - ref SDS C1 LG9L, and follow up meeting scheduling the meeting today,
211609 - reported on 150319 0800. ref SDS C6 N480
211611 - ..
211612 - On 150420 1752 submitted letter to Doctor Lee with agenda for meeting
211613 - the next day on 150421 1300 for EGD dilation. ref SDS C8 0M6I
211615 - ..
211616 - Applied pre-proc requirements for NPO after midnight, from letter on
211617 - 101015 1547. ref SDS 59 4J9L Last food was at......
211619 - ..
211620 - Stayed in Concord last night. This morning, Kathy drove us to VA
211621 - Medical Center at Mather AFB in Sacrmento.
211623 - ..
211624 - Checked into GI Department at the customer counter.
211625 -
211626 - 800-382-8387
211627 -
211628 - 916 843 7000
211629 -
211630 -
211632 - ..
211633 - Submitted Kathy's cell phone for designated driver.
211637 - ..
211638 - Kathy signed the discharge form affirming she will be designated
211639 - driver, and responsible to facilitate no driving for 24 hours.
211641 - ..
211642 - Nurse at customer counter asked questions on patient history to verify
211643 - ready for procedure, e.g., no allergies, and NPO after midnight to
211644 - avoid conflicts with anesthesia; no health problems, e.g., no
211645 - diabetes, alcohol, cigarettes.
211647 - ..
211648 - Waited in lobby for 5 minutes. Then the nurse Denise called to
211649 - prepare for procedure.
211650 -
211652 - ..
2117 -
2118 -
2119 - 0907
2120 -
212001 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
212002 -
212003 - Follow up ref SDS C1 EP75, ref SDS C0 EP75.
212004 -
212005 - This is different from prior procedures where vitals were initial case
212006 - setup prepared in a small office just off the lobby, and not in the
212007 - treatment center, reported on 120925 0900. ref SDS 86 PT5P
212009 - ..
212010 - The nurse took vitals...
212011 -
212012 - Weight..................
212013 - BP...................... 132 71
212014 - HR (pulse).............. 55
212015 - Temp....................
212017 - ..
212018 - Denise did major prepartion work. Configured on gurney and connected
212019 - equipment to monitor vitals during the procedure.
212021 - ..
212022 - Hazel set catheter IV for sedation. Required only 1 stick, so better
212023 - day than last time on 141107 0800. ref SDS C1 544G
212025 - ..
212026 - Case study on sticks required to set catheter is reported on 110429
212027 - 1230. ref SDS 75 UO3G
212029 - ..
212030 - Denise went through patient identification and medical profile
212031 - filling out forms on the computer.
212033 - ..
212034 - She asked about pain?
212036 - ..
212037 - Reported right knee MCL pain level 0 - 3, caused by running injury on
212038 - 150326, reported in case study on 140101 0600. ref SDS A8 6O6F
212039 - Background on the injury is reported with detail identifying MCL
212040 - damage is reported in the record the next day on 150327 0728.
212041 - ref SDS C7 K05I
212042 -
212043 - [...below on 150421 1210 at 1320 Doctor Lee advises that he
212044 - will report in Progress Notes injury to MCL right knee.
212045 - ref SDS 0 FU6I
212047 - ..
212048 - Waited about 30 minutes.
212049 -
212050 -
212051 -
212053 - ..
2121 -
2122 -
2123 - 1320
2124 -
212401 - Consent Signed EGD Dilation and Meeting Review Pending Issues
212402 - Consultation Pending Issues and Sign Consent for EGD Dilation
212403 -
212404 - Follow up ref SDS C1 RG9K, ref SDS C0 RG9K.
212405 -
212406 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation
212407 - procedure today.
212409 - ..
212410 - Doctor Lee will report in Progress Notes for the work today, patient
212411 - report of MCL injury to right knee, per meeting with Denise, earlier
212412 - today, above. ref SDS 0 6P9I
212413 -
212415 - ..
212416 - Swallowing Vomitting Difficulties Resolved with Triamcinolone Injections
212417 - Triamcinolone Injection Prevent LESV Contraction Avoid Swallowing Vomitting Problems
212418 -
212419 - Follow up ref SDS C1 VV6N, ref SDS C0 VV6N.
212420 -
212421 - Doctor Lee reported he received the letter sent to the VA yesterday on
212422 - 150420, submitting the agenda for the meeting today performing EGD
212423 - dilation. ref SDS C8 0M6I
212425 - ..
212426 - Doctor Lee further advised that he has not filed a referral to Doctor
212427 - Stewart on fixing failed fundoplication, planned during the meeting on
212428 - 150319 0800. ref SDS C6 TB5I After meeting on 150319, the doctor
212429 - decided to issue the referral to Doctor Stewart based on findings from
212430 - EGD dilation today.
212432 - ..
212433 - Doctor Lee indicated referral will be filed within 2 weeks, after
212434 - receiving results of biopsies taken during the procedure today.
212435 -
212436 - [On 150514 0130 letter to Doctor Lee requests file Progress
212437 - Notes for EGD Dilation today, and make referral to Doctor
212438 - Stewart, to prepare for meeting with Doctor Lee scheduled
212439 - on 150521. ref SDS D0 K37G
212441 - ..
212442 - [On 150514 0130 at 1326 received call from VA Medical
212443 - Center in San Francisco and scheduled meeting with Doctor
212444 - Stewart in General Surgery to review "redo" fundoplication
212445 - to recover from surgery failure in order to prevent
212446 - recurrence and compounding of ulcerations on LESV that
212447 - worsen achalasia swallowing problems. ref SDS D0 US53
212448 -
212449 -
212450 -
212451 -
212458 - ..
212459 - The doctor also said that he filed on the computer some notes, and
212460 - commented the patient can see it later today after the procedure using
212461 - the VA Internet medical records system. Not sure what this filing
212462 - covers. Advised that typically, VA doctor notes take 3 business days
212463 - for availability to the patient using the Internet.
212465 - ..
212466 - Doctor Lee plans to use Triamcinolone steroid injection during the
212467 - procedure today, based on favorable results, and planning during the
212468 - meeting on 150319 0800. ref SDS C6 6P9M
212470 - ..
212471 - Doctor Lee asked about swallowing problems?
212473 - ..
212474 - Past 4 weeks or so saliva tends to build up in the esophagus, so this
212475 - is a good time to do another dilation with triamcinolone steriod
212476 - injections, which resists contraction of LESV, so that effective
212477 - swallowing is maintained, as shown in Progress Notes on 111115 300.
212478 - ref SDS 81 AW6J and reported again in Progress Notes on 120925 0900.
212479 - ref SDS 86 E558
212481 - ..
212482 - Estimated LESV will engage today at about 16.5mm, based on prior
212483 - history when triamcinalone steriod injections were made.
212484 -
212485 - [...below on 150421 1210 at 1440 after the procedure Doctor
212486 - Lee reported LESV 16.5 mm. ref SDS 0 6P6G
212488 - ..
212489 - Signed consent for the procedure, which is not visible - there is
212490 - merely a black screen to sign.
212491 -
212492 -
212493 -
212494 -
212496 - ..
2125 -
2126 -
2127 - 1340
2128 -
212801 - OR EGD Dilation with Application Lidocaine
212802 - EGD Dilation Procedure in OR Application Lidocaine
212803 -
212804 - Follow up ref SDS C1 7V6I, ref SDS B2 7V6I.
212805 -
212806 - Denise wheeled the gurney into the OR for the procedure. Met
212807 - Christy.
212809 - ..
212810 - Everything went smoothly, as always.
212812 - ..
212813 - Christy applied conscious sedation using the catheter set by Hazel in
212814 - Preparation, per above. ref SDS 0 544G
212815 -
212816 - [...below on 150421 1210 Progress Notes report intravenous
212817 - medication applied for conscious sedation. ref SDS 0 P341
212819 - ..
212820 - The team then did the EDG/dilation procedure.
212821 -
212822 -
212823 -
212825 - ..
2129 -
2130 -
2131 - 1440
2132 -
213201 - Dilated 18 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee
213202 - Meeting Doctor Lee Present Results EGD Dilation Procedure 18 MM
213203 - Results EGD Dilation Procedure Meeting Doctor Lee Present 18 MM
213204 -
213205 - Follow up ref SDS C1 5H5J, ref SDS C0 5H5J.
213207 - ..
213208 - An hour or so after the procedure, met with Doctor Lee in the recovery
213209 - room.
213211 - ..
213212 - Doctor Lee advised that LESV contracted 1.5 mm from 18 mm down to 16.5
213213 - mm, since prior dilation 6 months ago on 141107 0800, ref SDS C1 5H5J,
213214 - and following up discussion this morning prior to the procedure, per
213215 - above. ref SDS 0 MQ4M This is significant improvement compared to 3
213216 - mm contraction to 15 mm, reported for prior EGD dilation on 141107
213217 - 0800. ref SDS C1 6P6G
213218 -
213219 - [On 150521 0800 meeting with Doctor Lee at VAMC in
213220 - Sacramento - concensus uncharacteristic vomitting after
213221 - recent EGD dilation procedure on 150421, due to patient not
213222 - eating slowly with small bites and drinking liquids
213223 - frequently, especially when eating meat products that have
213224 - high viscocity with esophageal tissue, and so tends to
213225 - stick, causing vomitting. ref SDS D2 WT9L
213227 - ..
213228 - This result further shows triamcinolone steroid injections
213229 - significantly compliment dilation process for maintaining effective
213230 - swallowing to recover from achalasia.
213232 - ..
213233 - Doctor Lee advised that triamcinolone steriod was injected again
213234 - today, in order to restore and maintain improved swallowing for the
213235 - next 6 months, as it has the past 2 years, since 120925...
213236 -
213237 - LESV Dilated
213238 - Date from - to
213239 - 150421 16.5 18.....triamcinolone.... ref SDS 0 I167
213240 - 141107 15 18.....triamcinolone.... ref SDS C1 I167
213241 - 140509 16.5 18...................... ref SDS B2 P680
213242 - 131115 16.5 18.....triamcinolone.... ref SDS A5 RZ45
213243 - 130416 18 18.....triamcinolone.... ref SDS 99 Y850
213244 - 130110 15 18.....triamcinolone.... ref SDS 94 Q333
213245 - 120925 15 18.....triamcinolone.... ref SDS 86 XB51
213246 - 120322 16.5 18...................... ref SDS 83 516N
213247 - 111115 16.5 18...................... ref SDS 81 IR57
213248 - 110819 15 16.5...triamcinolone.... ref SDS 80 J978
213249 - 110429 13 16.5...triamcinolone.... ref SDS 75 U23I
213250 - 110218 11 14.....triamcinolone.... ref SDS 71 AA5O
213251 - 101210 11 14...................... ref SDS 67 H347
213252 - 100827 11 15...................... ref SDS 55 JE6X
213253 - 100305 11 15...................... ref SDS 48 WR6L
213255 - ..
213256 - Background on triamcinolone injection is further reviewed in the
213257 - record for the meeting at the VA on 140509 0900. ref SDS B2 R26H
213259 - ..
213260 - Doctor Lee further advised that examination of LESV found ulceration
213261 - is less severe today, i.e., improved, from the prior examination on
213262 - 141107, as presented during the meeting on 150319 0800. ref SDS C6
213263 - N46O
213264 -
213265 - [...below on 150421 1210 Progress Notes found ulcerations
213266 - regressing (improving) to mere erosions. ref SDS 0 PXXY
213268 - ..
213269 - This aligns with increasing Omeprazole on adhoc basis to reduce
213270 - episodic effects of reflux, see case study on 140101...
213271 -
213272 - 150205........... ref SDS A8 ER7K
213273 - 150213........... ref SDS A8 2Z7I
213274 - 150214........... ref SDS A8 2Z7I
213275 - 150220........... ref SDS A8 OC6K
213276 - 150307........... ref SDS A8 773J
213277 - 150308........... ref SDS A8 6F5H
213278 - 150418........... ref SDS A8 V64N
213279 -
213280 -
213281 -
213282 -
213283 -
213284 -
213285 -
213286 -
2133 -
SUBJECTS
Medical Chart Progress Notes VA EGD Procedure Stricture Lower Esopha
5103 -
510401 - ..
510402 - Progress Notes EGD Dilation Today
510403 -
510404 - Follow up ref SDS C1 CY7I, ref SDS B2 CY7I.
510406 - ..
510407 - VA website is at...
510408 -
510409 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
510410 -
510432 - 1. LOCAL TITLE: EGD 60111
510433 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
510434 - DATE OF NOTE: APR 21, 2015@13:00 ENTRY DATE: APR 24, 2015@09:51:20
510435 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
510436 - URGENCY: STATUS: COMPL
510438 - ..
510439 - 2. PATIENT NAME:
510446 - ..
510447 - 3. NAME OF PROCEDURES:
510448 -
510449 - 1. Esophagogastroduodenoscopy.
510450 - 2. Endoscopic biopsy.
510451 - 3. TTS balloon dilation of esophagus.
510453 - ..
510454 - 4. ATTENDING PHYSICIAN:
510455 - Randall E. Lee, M.D.
510457 - ..
510458 - 5. INDICATIONS:
510461 -
510462 - 1. 70-year-old man with history of achalasia. After
510463 - undergoing coronary artery bypass and graft, he underwent
510464 - laparoscopic myotomy and fundoplication at the San
510465 - Francisco VA. He subsequently developed acid reflux
510466 - complicated by a recurrent distal esophageal stricture.
510468 - ..
510469 - 2. His last EGD was November 2014 at which time he had a mild
510470 - area of esophageal stenosis starting at approximately 16.5
510471 - mm that was dilated to 18 mm.
510473 - ..
510474 - This should be corrected to reflect LESV contracted to 15 mm, reported
510475 - by Doctor Lee on 141107 0800. ref SDS C1 6P6G
510477 - ..
510478 - Progress Notes EGD Dilation procedure on 150421 continues...
510479 -
510480 - 3. There was also a shallow ulceration of the GE junction that
510481 - previously was shown to be chronic inflammation.
510483 - ..
510484 - 4. The gastric fundus was surgically altered consistent with a
510485 - known history of fundoplication, but a hiatal hernia was
510486 - also noted suggesting relaxation of the fundoplication.
510488 - ..
510489 - Progress Notes for procedure on 140509, described fundoplication
510490 - appears to be loosening. ref SDS B2 I93F
510492 - ..
510493 - On 150319, Doctor Lee advised that fundoplication has unravelled.
510494 - ref SDS C6 KN6F
510496 - ..
510497 - Progress Notes EGD Dilation procedure on 150421 continues...
510498 -
510499 - 5. Approximately 2 weeks ago, the patient noted some
510500 - deterioration in his ability to swallow. He estimates that
510501 - his esophagus has decreased to 16 mm diameter.
510503 - ..
510504 - Aligns with meeting this morning, shown above. ref SDS 0 P55L
510506 - ..
510507 - Progress Notes EGD Dilation procedure on 150421 continues...
510508 -
510509 - 6. Unrelatedly, he also notes that he has been suffering from
510510 - some medial right knee pain approximately 0-5/10, which he
510511 - attributes to having injured it while he was hiking.
510513 - ..
510514 - MCL injury occurred while sprinting across the street during rush hour
510515 - on 150326, reported in patient history case study on 140101 0600.
510516 - ref SDS A8 6O6F
510518 - ..
510519 - Progress Notes EGD Dilation procedure on 150421 continues...
510520 -
510521 - 6. CONSENT:
510522 -
510523 - The risks, benefits, and alternatives to this procedure
510524 - including but not limited to the risks of bleeding and bowel
510525 - perforation were explained to the patient. The patient
510526 - understood and provided a written informed consent.
510528 - ..
510529 - 7. INTRAVENOUS MEDICATION:
510530 -
510531 - 1. Diphenhydramine 50 mg.
510532 - 2. Fentanyl 250 mcg.
510533 - 3. Midazolam 4 mg.
510535 - ..
510536 - Why was Fentanyl 250 increased from 150 mcg for prior procedure on
510537 - 141107 0800, ref SDS C1 P341, and further increased today from 200 mcg
510538 - for procedure on 140509? ref SDS B1 P341
510540 - ..
510541 - Similarly, why was Midazolam 4 mg reduced from 5 mg for prior
510542 - procedure on 141107 0800. ref SDS C1 P341
510544 - ..
510545 - Research on the Internet found...
510546 -
510547 - 1. Midazolam short-acting central nervous system (CNS)
510548 - depressant of the benzodiazepine class developed by
510549 - Hoffmann-La Roche in the 1970s.
510550 -
510551 - http://en.wikipedia.org/wiki/Midazolam
510553 - ..
510554 - Midazolam has a fast recovery time and is the most
510555 - commonly used benzodiazepine as a premedication for
510556 - sedation; less commonly, it is used for induction and
510557 - maintenance of anesthesia.
510559 - ..
510560 - Midazolam, like many other benzodiazepines, has a rapid
510561 - onset of action, high effectiveness, and low toxicity
510562 - level. Drawbacks of midazolam include drug
510563 - interactions, tolerance, and withdrawal syndrome, as
510564 - well as adverse events including cognitive impairment
510565 - and sedation.
510567 - ..
510568 - 2. Midazolam Hydrochloride: Oral syrup (2mg)
510569 -
510570 - http://www.cvs.com/drug/midazolam-hydrochloride/oral-syrup/2mg
510572 - ..
510573 - MIDAZOLAM (MID ay zoe lam) 2 mg is a benzodiazepine
510574 - used to cause relaxation or sleep before surgery and to
510575 - block the memory of the procedure.
510577 - ..
510578 - Progress Notes EGD Dilation procedure on 150421 continues...
510579 -
510580 - 8. PROCEDURE:
510581 -
510582 - 1. In the Sacramento VA GI Endoscopy Unit, the patient was
510583 - placed in the left lateral decubitus position.
510585 - ..
510586 - 2. Oxygen at 2 liters per minute by nasal cannula was administered.
510588 - ..
510589 - 3. Continuous oximetric and hemodynamic monitoring was initiated.
510591 - ..
510592 - 4. Intravenous sedation was administered in divided doses.
510594 - ..
510595 - 5. After a bite block was placed in the patient's mouth, an
510596 - Olympus GIF-H180J video gastroscope was advanced under
510597 - direct vision into the esophagus.
510599 - ..
510600 - 6. The esophageal lumen was noted to be dilated and some
510601 - residual saliva was easily irrigated and suctioned away to
510602 - achieve a good view of the esophagus.
510604 - ..
510605 - 7. The gastroscope was then advanced into the descending
510606 - duodenum and retroflexed views of the incisura, fundus, and
510607 - cardia were performed.
510609 - ..
510610 - Photographs of esophagus and stomach for procedure on 141107...
510612 - ..
510613 - For some reason the VA does not submit photographs from EGD dilation
510614 - procedure on 150421.
510615 -
510616 - [On 150521 0800 during meeting with Doctor Lee for follow
510617 - up review of EGD dilation Progress Notes, explained
510618 - photographs are not available from VA customer Internet
510619 - server. ref SDS D2 E65J
510621 - ..
510622 - [On 150616 1624 received photographs on CD in word.docx
510623 - file from Phillip in ROI Department at VA MC in Sacramento
510624 - (Mather) showing Dor fundoplication in tact on 131115,
510625 - beginning to unravel on 140507, further unraveled on
510626 - 141107, and unraveled on 150421. ref SDS D3 XW6M
510628 - ..
510629 - Progress Notes EGD Dilation procedure on 150421 continues...
510630 -
510631 - 8. Random biopsies taken from the gastric antrum labeled A,
510632 - from the gastric body labeled B, from the gastric cardia at
510633 - 40 cm at the top of the gastric folds within the hiatal
510634 - hernia pouch labeled C, the GE junction at 39 cm labeled D,
510635 - and from the esophagus at 35 cm labeled E.
510636 -
510637 - [...below on 150421 pathology report on results of
510638 - biopsy specimens A-E, ref SDS 0 1B5F, diagnose chronic
510639 - gastritis. ref SDS 0 VE5K squamous mucosa with acute
510640 - and chronic inflammation. ref SDS 0 PH8F
510642 - ..
510643 - On 150319 0800 meeting Doctor Lee reports hiatal hernia reflects
510644 - failure fundoplication that causes increased acid burn on LESV leading
510645 - to ulceration; this condition increases stricture that in turn
510646 - increases swallowing problems, despite increased Omeprazole
510647 - medication. ref SDS C5 N535
510649 - ..
510650 - Progress Notes EGD Dilation procedure on 150421 continues...
510651 -
510652 - 9. Subsequently, a TTS balloon dilator was advanced through
510653 - the endoscope and positioned across the distal esophagus.
510654 - This was inflated sequentially from 15 to 16.5 to 18 mm.
510655 - The esophagus mucosa was seen to contact the balloon at
510656 - approximately 16.5 mm. After inflation to 18 mm, there was
510657 - no mucosal tearing identified.
510658 -
510659 - [On 150521 0800 meeting with Doctor Lee at VAMC in
510660 - Sacramento - concensus uncharacteristic vomitting after
510661 - recent EGD dilation procedure on 150421, due to patient
510662 - not eating slowly with small bites and drinking liquids
510663 - frequently, especially when eating meat products that
510664 - have high viscocity with esophageal tissue, and so
510665 - tends to stick, causing vomitting. ref SDS D2 WT9L
510667 - ..
510668 - 10. The area was then injected with triamcinolone acetate at a
510669 - concentration of 40 mg/mL, a total dose of 3 mL. The
510670 - stomach was decompressed and the gastroscope removed.
510671 -
510672 - LESV Dilated
510673 - Date from - to
510674 - 150421 16.5 18.....triamcinolone..3.0mL.... ref SDS 0 HU42
510675 - 141107 15 18.....triamcinolone..4.0mL.... ref SDS C1 I167
510676 - 140509 16.5 18............................. ref SDS B2 P680
510677 - 131115 16.5 18.....triamcinolone..2.0mL.... ref SDS A5 RZ45
510678 - 130416 18 18.....triamcinolone..2.0mL.... ref SDS 99 Y850
510679 - 130110 15 18.....triamcinolone..3.0mL.... ref SDS 94 Q333
510680 - 120925 15 18.....triamcinolone..4.0mL.... ref SDS 86 XB51
510681 - 120322 16.5 18............................. ref SDS 83 516N
510682 - 111115 16.5 18............................. ref SDS 81 IR57
510683 - 110819 15 16.5...triamcinolone..2.5mL.... ref SDS 80 J978
510684 - 110429 13 16.5...triamcinolone..3.5mL.... ref SDS 75 U23I
510685 - 110218 11 14.....triamcinolone..2.0mL.... ref SDS 71 AA5O
510686 - 101210 11 14............................. ref SDS 67 H347
510687 - 100827 11 15............................. ref SDS 55 JE6X
510688 - 100305 11 15............................. ref SDS 48 WR6L
510690 - ..
510691 - 9. COMPLICATIONS:
510692 -
510693 - None immediate.
510695 - ..
510696 - Ulceration LESV and Hiatal Hernia New Findings Fundoplication Failed
510697 -
510698 - Follow up ref SDS C1 P396, ref SDS B2 P396.
510699 -
510700 - 10. FINDINGS:
510701 -
510702 - 1. Previous area of esophageal stricture noted again at 39 cm.
510703 - Probable starting diameter was approximately 16.5 mm that
510704 - was then dilated to 18 mm.
510706 - ..
510707 - 2. Several areas of erosion in the distal esophagus at the GE
510708 - junction and extending upwards for approximately 1 cm.
510710 - ..
510711 - 3. Gastric fundus surgically altered consistent with known
510712 - history of fundoplication.
510714 - ..
510715 - 4. Hiatal hernia visible.
510717 - ..
510718 - Why don't the Progress Notes for work today report fundoplication
510719 - loosening/unravelled based on photographic evidence, and evidence of
510720 - hiatal hernia, and associate this with increased acid reflux causing
510721 - ulceration to LESV?
510723 - ..
510724 - A year ago, on 140509 0900 Progress Notes report hiatal hernia,
510725 - ref SDS B2 P34O; and further state "...hiatal hernia suggests the
510726 - fundoplication appears to be loosening." ref SDS B2 I93F Hiatal
510727 - hernia was also reported 6 months ago on 141107 0800. ref SDS C1 QD6O
510729 - ..
510730 - On 150319 0800 meeting with Doctor Lee indicated fundoplication
510731 - constructed by Doctor Stewart to protect LESV from acid reflux, has
510732 - unraveled, i.e., failed. This caused hiatal hernia. Failure of
510733 - fundoplication also caused ulceration to LESV from increased exposure
510734 - to acid reflux. ref SDS C6 N535; Doctor Lee planned referral to Doctor
510735 - Stewart to assess re-fundoplication or other measures. ref SDS C6 JQ5J
510737 - ..
510738 - Progress Notes continue...
510739 -
510740 - 5. Area of mucosal discoloration surrounding the pylorus of
510741 - unclear significance.
510742 -
510743 - 6. Normal pylorus.
510745 - ..
510746 - 7. Normal duodenum to D2.
510748 - ..
510749 - 11. IMPRESSION:
510750 -
510751 - 1. Gastroesophageal reflux stricture appears to be not
510752 - reforming as rapidly as previously. In addition, the
510753 - previously identified ulcerations appear to be regressing,
510754 - although slowly, as these are now more erosions rather
510755 - than ulcerations.
510757 - ..
510758 - "Gastroesophageal reflux stricture appears to be not reforming as
510759 - rapidly," reflects report that dilation of LESV started at 16.5 mm
510760 - today, rather than 15 mm, per above, ref SDS 0 HU42, which reflects
510761 - injection of triamcinalone steriod, which was continued today,
510762 - ref SDS 0 HU5P, as discussed with the doctor before starting the
510763 - procedure, shown above. ref SDS 0 P55L
510765 - ..
510766 - Ulceration regressing to mere erosions, shows possible recovery from
510767 - prior findings on EGD dilation procedure on 141107 0800, ref SDS C1
510768 - MG6N; aligns with discussion after the procedure in the recovery room,
510769 - per above. ref SDS 0 QQ7N
510771 - ..
510772 - This aligns with increasing Omeprazole on adhoc basis to reduce
510773 - episodic effects of reflux, see case study on 140101...
510774 -
510775 - 150205........... ref SDS A8 ER7K
510776 - 150213........... ref SDS A8 2Z7I
510777 - 150214........... ref SDS A8 2Z7I
510778 - 150220........... ref SDS A8 OC6K
510779 - 150307........... ref SDS A8 773J
510780 - 150308........... ref SDS A8 6F5H
510781 - 150418........... ref SDS A8 V64N
510783 - ..
510784 - For some reason there is no report of fundoplication loosening or
510785 - unravelling as found and previously associated with hiatal hernia
510786 - reported in the EGD dilation procedure on 140509 0900. ref SDS B1 I93F
510788 - ..
510789 - On 150319 0800 meeting with Doctor Lee indicated acid reflux increased
510790 - causing ulceration and constriction to LESV that hampers swallowing,
510791 - because fundoplication has unraveled, ref SDS C4 N535; remedy -
510792 - referral to Doctor Stewart to assess re-fundoplication or other
510793 - measures. ref SDS C4 JQ5J
510795 - ..
510796 - Progress Notes EGD Dilation procedure on 141107 continues...
510797 -
510798 - 12. RECOMMENDATIONS:
510799 -
510800 - 1. Await the pathology results.
510801 -
510802 - 2. Continue omeprazole 20 mg twice daily.
510804 - ..
510805 - 3. Repeat EGD and dilation in approximately 6 months.
510806 -
510807 - [On 150925 0336 VA scheduled next meeting for EGD
510808 - dilation on 151204 0800, 8 months since prior meeting
510809 - today on 150421. ref SDS D4 SR6L
510811 - ..
510812 - 4. After biopsies are available, at the patient's request,
510813 - referral back to San Francisco VA Surgical Clinic for
510814 - consideration of repeat fundoplication therapy.
510816 - ..
510817 - Aligns with planning on 150319 0800 during meeting with Doctor Lee
510818 - indicated acid reflux increased causing ulceration and constriction to
510819 - LESV that hampers swallowing, because fundoplication has unraveled,
510820 - i.e., failed, ref SDS C6 N535; remedy - referral to Doctor Stewart to
510821 - assess re-fundoplication or other measures. ref SDS C6 JQ5J
510822 -
510823 - [On 150514 0130 at 1326 received call from VA Medical
510824 - Center in San Francisco and scheduled meeting with
510825 - Doctor Stewart in General Surgery to review "redo"
510826 - fundoplication to recover from surgery failure in order
510827 - to prevent recurrence and compounding of ulcerations on
510828 - LESV that worsen achalasia swallowing problems.
510829 - ref SDS D0 US53
510831 - ..
510832 - [On 150429 1332 letter to Doctor Lee submits record
510833 - meeting with Doctor Stewart at VA Medical Center in San
510834 - Francisco, completing referral for consideration redo
510835 - Dor fundoplication, resolve hiatal hernia and ulceration
510836 - LESV. ref SDS C9 WP8J
510838 - ..
510839 - 13. DISPOSITION:
510840 -
510841 - 1. The patient was observed in the Recovery Room then
510842 - discharged to home with a companion.
510843 -
510844 - 2. I reviewed the endoscopic findings with the patient prior
510845 - to discharge.
510847 - ..
510848 - 14. TIME START: 1352 hours.
510849 - TIME END: 1418 hours.
510851 - ..
510852 - D: 04/21/2015
510853 - T: 04/23/2015
510854 - Job Number: 1404673
510855 - 15. VJJ/CMTS
510856 - $end:
510857 -
510858 -
510860 - ..
510861 - Biopsy Reports No Barrett's Esophabus Precursor to Cancer
510862 -
510863 - Follow up ref SDS B9 1B5F, ref SDS B1 1B5F.
510864 -
510865 - 16. VA Pathology Reports
510866 -
510867 - 1. Type of Report: Surgical Pathology
510868 - Specimen: A GASTRIC ANTRUM
510869 - B GASTRIC BODY
510870 - C GASTRIC CARDIA AT 40CM
510871 - D GE JUNCTION AT 39CM
510872 - E ESOPHAGUS AT 35CM
510874 - ..
510875 - 2. Date Obtained: 21 Apr 2015
510877 - ..
510878 - 3. Performing Location: NORTHERN CALIFORNIA HEALTH CARE SYSTEM - MARTINEZ DIVISION
510879 - 150 Muir Road
510880 - Martinez 94553
510882 - ..
510883 - 4. Date Completed: 23 Apr 2015
510885 - ..
510886 - 5. Reporting Lab: SACRAMENTO VAMC [CLIA# 05D0988241]
510887 - 10535 HOSPITAL WAY
510888 - MATHER, CA 95655-4200
510890 - ..
510891 - 6. Date Spec taken: Apr 21, 2015 Pathologist:PATRICIA L DALTON MD
510892 - Date Spec rec'd: Apr 22, 2015 10:11 Resident: AMIR GHORBANI MD
510893 - Date completed: Apr 23, 2015 Accession #: SP 15 3296
510894 - Submitted by: LEE,RANDALL E Practitioner:RANDALL E LEE MD
510896 - ..
510897 - 7. Specimen: A GASTRIC ANTRUM
510898 - B GASTRIC BODY
510899 - C GASTRIC CARDIA AT 40CM
510900 - D GE JUNCTION AT 39CM
510901 - E ESOPHAGUS AT 35CM
510903 - ..
510904 - 8. Brief Clinical History: 70-YEAR-OLD MAN WITH HX OF
510905 - ACHALASIA, MYOTOMY, GERD STRICTURE
510907 - ..
510908 - 9. Preoperative Diagnosis: SURVEILLANCE
510910 - ..
510911 - 10. Operative Findings: GASTRIC ANTRAL MUCOSAL MOTTLING, NORMAL
510912 - GASTRIC BODY, EROSIONS AT GE JUNCTION 39CM, ESOPHAGUS
510913 - UNREMARKABLE AT 35CM
510915 - ..
510916 - 11. Gross description:
510917 -
510918 - A. Received in formalin with proper patient identification
510919 - labeled "gastric antrum" are multiple fragments of
510920 - grey-tan tissue measuring 0.8 x 0.5 x 0.1 cm in
510921 - aggregate. Totally submitted in one cassette.
510923 - ..
510924 - B. Received in formalin with proper patient identification
510925 - labeled "gastric body" are multiple fragments of
510926 - grey-tan tissue measuring 0.8 x 0.4 x 0.1 cm in
510927 - aggregate. Totally submitted in one cassette.
510929 - ..
510930 - C. Received in formalin with proper patient identification
510931 - labeled "gastric cardia 40 cm" are three fragments of
510932 - white-tan tissue measuring 0.4 x 0.3 x 0.1 cm in
510933 - aggregate. Totally submitted in one cassette.
510935 - ..
510936 - D. Received in formalin with proper patient identification
510937 - labeled "GE junction 39 cm" are multiple fragments of
510938 - grey-tan tissue measuring 0.9 x 0.3 x 0.1 cm in
510939 - aggregate. Totally submitted in one cassette.
510941 - ..
510942 - E. Received in formalin with proper patient identification
510943 - labeled "esophagus 35 cm" are multiple fragments of
510944 - white-tan tissue measuring 0.9 x 0.3 x 0.1 cm in
510945 - aggregate. Totally submitted in one cassette. (AG
510946 - 4/22/2015 01:10 PM)
510948 - ..
510949 - 12. Microscopic exam/diagnosis: (Date Spec taken: Apr 21,
510950 - 2015)
510952 - ..
510953 - A. STOMACH, ANTRUM (BIOPSY):
510954 -
510955 - 1. CHRONIC GASTRITIS
510956 -
510957 - 2. NO EVIDENCE OF HELICOBACTER PYLORI BY WARTHIN STARRY
510958 - STAIN
510960 - ..
510961 - B. STOMACH, BODY (BIOPSY): CHRONIC GASTRITIS
510963 - ..
510964 - C. STOMACH, CARDIA AT 40CM (BIOPSY): FUNDIC MUCOSA WITH
510965 - CHRONIC GASTRITIS
510967 - ..
510968 - D. GASTROESOPHAGEAL JUNCTION, 39CM (BIOPSY):
510969 -
510970 - 1. SQUAMOCOLUMNAR MUCOSA WITH CHRONIC INFLAMMATION
510971 - 2. NEGATIVE FOR INTESTINAL METAPLASIA (BARRETT'S ESOPHAGUS)
510973 - ..
510974 - E. ESOPHAGUS, 35CM (BIOPSY): SQUAMOUS MUCOSA WITH ACUTE
510975 - AND CHRONIC INFLAMMATION
510977 - ..
510978 - Performing Laboratory:
510979 - Surgical Pathology Report Performed By:
510980 - SACRAMENTO VAMC [CLIA# 05D0988241]
510981 - 10535 HOSPITAL WAY MATHER, CA 95655-4200
510982 -
510983 -
510985 - ..
510986 - Doctor Lee Letter Report Results EGD Dilation 140509
510987 -
510988 - Follow up ref SDS B9 N57M, ref SDS B1 N57M.
510989 -
510990 - Doctor Lee's post-procedure letter received on 150324, and incoporated
510991 - into Progress Notes, says...
510993 - ..
510994 - 1. In Reply Refer To: Sacramento VA
510995 - Gastroenterology (111/SMAT)
511002 -
511003 - 2. 13 May 2015
511007 - ..
511008 - 3. You had an endoscopic examination of your esophagus, stomach,
511009 - and duodenum (EGD) at the Sacramento VA Medical Center on 21
511010 - April 2015. The biopsies showed NO cancer, NO precancerous
511011 - condition (dysplasia / Barrett's esophagus), nor any infection.
511012 - I dilated your esophagus to 18mm
511014 - ..
511015 - 4. The biopsies did continue to show evidence of acid reflux
511016 - damage in the esophagus, and some inflammation in the stomach
511017 - and duodenum, reinforcing the need for continued use of the
511018 - acid-blocking medication (omeprazole).
511020 - ..
511021 - 5. As you requested, today I sent a consultation request to the
511022 - Surgery Department at the San Francisco VAMC for reevaluation
511023 - of your hiatal hernia repair.
511025 - ..
511026 - Does not mentioning redoing fundoplication indicated this is
511027 - necessarily implied and associated with hiatal hernia, as discussed
511028 - during the meeting on 150319 0800. ref SDS C6 KN6F The doctor's
511029 - progress notes on 140509 say in part "Appearance of hiatal hernia
511030 - suggests the fundoplication appears to be loosening." ref SDS B2 I93F
511031 -
511032 - [On 150520 1107 letter to Doctor Lee submitting agenda for
511033 - meeting scheduled 150521, thanks the doctor for filing
511034 - referral to Doctor Stewart in General Surgery at VAMC in
511035 - San Francisco. ref SDS D1 NJ71
511037 - ..
511038 - Doctor Lee's letter continues...
511039 -
511040 - I'll look forward to our next visit.
511042 - ..
511043 - 6. Truly yours,
511045 - ..
511046 - 7. Randall E. Lee, MD, FACP
511047 - Gastroenterologist, VA NCHCS
511048 - 916-366-5339
511049 -
511050 - 8. /es/ Randall E. Lee, MD
511051 - Staff Physician, Gastroenterology
511052 - Signed: 05/13/2015 09:09
511053 -
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511064 -
511065 -
511066 -