THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com
S U M M A R Y
DIARY: June 23, 2015 01:00 PM Tuesday;
Rod Welch
VA MCSF meeting Doctor Stewart assess redo fundoplication.
1...Summary/Objective
2...Work Plan Redo Fundoplication and Correct Hiatal Hernia
3...Fundoplication Repair to Resolve Hiatal Hernia Ulceration
4...Medical Chart Progress Notes Doctor Stewart General Surgery Meeting 150623
..............
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CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 15
3503 -
3503 - ..
3504 - Summary/Objective
3505 -
350501 - Follow up ref SDS D3 0000. ref SDS D2 0000.
350502 -
350503 -
350504 -
350505 -
350506 - [On 150624 0924 letter notified Doctor Lee of work plan to
350507 - try controlling ulceration of LESV by increasing PPI with
350508 - Omeprazole rather than chance performing high risk surgery
350509 - to repair Dor fundoplication, and that Doctor Stewart
350510 - ordered H2 Blocker for Doctor Lee to consider supplementing
350511 - PPI to control acid reflux. ref SDS D9 OP91
350512 -
350513 -
350514 -
350515 -
350517 - ..
3506 -
3507 -
3508 - Background
3509 -
350901 - On 050629 meeting Primary Care swallowing and vomitting problems
350902 - reported. ref SDS 1 K78K
350904 - ..
350905 - On 050714 barrium swallow test, ref SDS 2 2I4S, showed esophagus
350906 - distorted by swallowing problems. ref SDS 2 WE4H
350908 - ..
350909 - On 050816 meeting Primary Care Doctor Sandhu diagnoses achalasia.
350910 - ref SDS 3 DG8G Ultrasound test ordered to verify initial diagnosis of
350911 - swallowing and vomitting problems. ref SDS 3 6E7H Primary Care made
350912 - referral to GI clinic for care to resolve swallowing problems.
350913 - ref SDS 3 0G7M
350915 - ..
350916 - On 050830 ultrasound test evaluate swallowing problems possible
350917 - diagnosis achalasia. ref SDS 4 DG8G
350919 - ..
350920 - On 050830 results received barrium swallow test performed on 050714,
350921 - findings in the lower espohagus and gastroesophageal junction are
350922 - consistent with achalasia - recommend endoscopic examination.
350923 - ref SDS 4 6H9S
350925 - ..
350926 - On 050906 report ultrasound test on 050830, finds no cause for
350927 - swallowing problems and does not diagnose achalasia. ref SDS 5 BM6R
350929 - ..
350930 - On 051202 meeting GI Clinic Doctor Lee diagnoses achalasia.
350931 - ref SDS 6 HP9H Orders endoscopy (EGD) test to verify diagnosis of
350932 - achalasia and assess for cancer. ref SDS 6 NZ5H
350934 - ..
350935 - On 051209 GI Clinic endoscopy examination preliminary findings no
350936 - evidence of cancer, ref SDS 7 0001; biopsy report should be submitted
350937 - in a few weeks to confirm status of cancer, ref SDS 7 PY5J, and if so,
350938 - then a procedure can be schedule for next month to dilate the
350939 - exophageal sphincter valve. ref SDS 7 NZ5H
350941 - ..
350942 - On 051222 biopsy reports no evidence of cancer. ref SDS 8 FT6M
350944 - ..
350945 - On 060111 received letter from Doctor Lee in the Gastrointestinal (GI)
350946 - Clinic reporting that the biopsy was negative for cancer and
350947 - infection; next step is manometry test to verify achalasia, then
350948 - treatment for achalasia. ref SDS 9 4Q3R
350950 - ..
350951 - On 060125 manomety test scheduled for 060209 0800. ref SDS 10 GG9I
350953 - ..
350954 - On 060209 meeting at VA Mather AFB in Sacramento, test was postponed
350955 - until 060223, due to equipment failure. ref SDS 11 OW6M
350957 - ..
350958 - On 060221 Jimmy in GI Department at Sacramento VA Medical Center
350959 - reports manometry equipment still broken; has been sent out for
350960 - repairs and there is no date at this time on when the equipment will
350961 - be available for use at the VA. ref SDS 12 ND7M
350963 - ..
350964 - On 060330 endoscopy follow up examination at GI Department Sacramento
350965 - Medical Center - Doctor Lee finds no evidence cancer performed at VA
350966 - Sacramento condition precedent treatment recover from achalasia.
350967 - ref SDS 13 VX4G
350969 - ..
350970 - On 060330 manometry test performed by Doctor Lee at VA in Sacramento,
350971 - ref SDS 13 MC7P, verifies diagnosis swallowing and vomitting problems
350972 - caused by achalasia, ref SDS 13 MD4N, patient meets criteria for
350973 - treatment with pneumatic dilation. ref SDS 13 MD5G
350975 - ..
350976 - On 060505 Martinez VA GI clinic Doctor Lee reported equipment and
350977 - pneumatic balloon materials on hand to perform dilation for treating
350978 - achalasia; treatment delayed until diagnostic data is received from
350979 - Sacramento VA Medical Center from manometry test performed on 060330;
350980 - doctor following up to obtain data; will submit test data to patient
350981 - during the week of 060508, along with a schedule to treat achalasia.
350982 - ref SDS 14 FT6M
350984 - ..
350985 - On 060614 Martinez VA GI clinic reports increased work load treating
350986 - soldiers returning from war in Iraq requires prioritizing; patient
350987 - advocate, Rubin Soto, will coordinate with the GI Clinic notifying the
350988 - customer of the schedule based on current priorities. ref SDS 15 J86N
350990 - ..
350991 - On 070220 letter to VA asks about progress getting test results from
350992 - VA in Sacramento, and scheduling surgery for achalasia, ref SDS 16
350993 - 5R5R
350995 - ..
350996 - On 090812 1030 continued vomitting achalasia causes weight loss 30
350997 - pounds in a few months, Primary Care physician notified GI clinic to
350998 - review schedule for dilation to relieve achalasia. ref SDS 17 7L5O
351000 - ..
351001 - On 090908 meeting GI Clinic in Martinez reports treatment for
351002 - achalasia still waiting to receive results for manometry test on
351003 - 060330, at Sacramento VA Medical Center. ref SDS 18 HX46 Prepared new
351004 - work plan to treat achalasia without manometry test results, because
351005 - the doctor performed the test 3 years ago, and is so knows results
351006 - consistent with achalasia, shown on 060330 0712, ref SDS 13 MD4N;
351007 - schedules treatment for achalasia after treadmill stress test,
351008 - ref SDS 18 BU6W, to evaluate new chest pains hiking hills at Lafayette
351009 - Reservoir which have not occurred doing extended exercise hiking 3 -
351010 - 14 miles a day over the past 5 years. ref SDS 18 MY4N
351012 - ..
351013 - On 091021 report history achalasia issue during meeting with
351014 - cardiothoracic surgery team to prepare for heart bypass surgery the
351015 - next day. ref SDS 20 NX6M Surgery team will coordinate with
351016 - anesthesia team to provide swallowing relief during heart surgery to
351017 - prevent choking. ref SDS 20 R78O
351019 - ..
351020 - On 091022 0700 meeting anesthesia team - Doctor Brezinski not familiar
351021 - with achalasia - asked if achalasia has been reported to the VA?
351022 - ref SDS 21 JF9K While being prepared with IVs for surgery, patient
351023 - assists anesthesia find VA records on achalasia, ref SDS 21 2W4K;
351024 - Doctor Brezenski makes plans for patient care and safety so that
351025 - achalasia does not risk death during heart surgery. ref SDS 21 GX4J
351027 - ..
351028 - On 091022 cabg x4 cardiothoracic surgery San Francisco Medical Center.
351029 - ref SDS 21 PQWU
351031 - ..
351032 - On 091030 0800 at 1406 meeting with Doctor Stewart at San Francisco
351033 - Medical Center during recovery from heart surgery, proposes Heller
351034 - Myotomy surgery rather than pneumatic (balloon) dilation as more
351035 - effective and longer lasting solution to recover from swallowing and
351036 - vomitting problems caused by achalasia. ref SDS 24 KE3B
351038 - ..
351039 - On 091030 0800 at 1430 received documentation from GI Department at
351040 - San Francisco Medical Center - review shows 3 different treatments for
351041 - achalasia - pills, pneumatic dilation, Heller Myotomy surgery.
351042 - ref SDS 24 495I
351044 - ..
351045 - On 091030 0800 at 1440 meeting cardiothoracic surgery team; Doctor
351046 - Ratcliff concerned about how to maintain nutrition for the patient to
351047 - recover from heart surgery while digestion remains problematic due to
351048 - achalasia; proposes feeding tube for several months until Heller
351049 - Myotomy surgery. ref SDS 24 03GF
351051 - ..
351052 - On 091216 Heller Myotomy surgery at San Francisco VA Medical Center to
351053 - recover from achalasia. 091216 0600, ref SDS 36 KE9U
351055 - ..
351056 - On 100202 meeting with Doctor Lee - report swallowing and vomitting
351057 - problems 3 months after Heller Myotomy surgery. Doctor explains
351058 - achalasia disease breaks nerve connections from the brain that
351059 - contract the esophagus to force food and liquid from the mouth through
351060 - the esophagus; as well broken nerve connections prevent the lower
351061 - esophageal sphincter valve (LESV) to relax so that content can pass
351062 - into the stomach. Without esophageal contractions, food and liquid
351063 - can only reach the stomach with gravity, but since the LESV won't
351064 - relax the patient continues to have swallowing and vomitting problems,
351065 - despite Heller Myotomy surgery on 091216, intended to maintain
351066 - adequate opening into the stomach. ref SDS 47 485W
351068 - ..
351069 - On 100305 meeting at GI Clinic in Martinez, EGD procedure dilated LESV
351070 - from 11 to 15 mm. ref SDS 48 WR6L
351072 - ..
351073 - On 100827 meeting at GI Clinic in Martinez, EGD procedure dilated LESV
351074 - from 11 to 15 mm. ref SDS 55 JE6X
351076 - ..
351077 - On 101210 EGD procedure dilated esophageal sphincter valve (LESV)
351078 - without sedation, ref SDS 67 BE7K - dilated LESV again from 11 to 14
351079 - mm. ref SDS 67 BF6L
351081 - ..
351082 - On 101216 1021 letter commends medical team for excellent work, and
351083 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
351085 - ..
351086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using
351087 - anesthesia with Fentanyl. ref SDS 71 PQWY LESV dilated 11 - 14 mm,
351088 - and added triamcinolone steriod injections to resist contraction of
351089 - LESV so that swallowing is maintained over the next 3 month cycle.
351090 - ref SDS 71 SR4G
351092 - ..
351093 - On 110429 0830 5th EGD dilation at VA in Martinez - triamcinolone
351094 - steriod injections worked well to resist contraction of LESV so that
351095 - swallowing was maintained over the prior 3 month cycle, ref SDS 75
351096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 75 U23I, and
351097 - triamcinolone injections were continued. ref SDS 75 SS5N
351099 - ..
351100 - On 110607 1414 visited GI Department, ref SDS 77 HC5H, and Charlene
351101 - reported a computer mistakes requires scheduling next EGD dilation on
351102 - 110819 0830. ref SDS 77 N642 Requested meeting with Doctor Lee to
351103 - review pending action items. ref SDS 77 4P6J,
351105 - ..
351106 - On 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter
351107 - valve. Triamcinolone steriod injections worked well to resist
351108 - contraction of LESV so that swallowing is maintained over the prior 3
351109 - month cycle, so LESV dilated from 15 - 16.5 mm, ref SDS 80 J978, and
351110 - triamcinolone injections were continued. ref SDS 80 J985
351112 - ..
351113 - On 111115 1300 EGD dilation procedure - triamcinolone steriod injections
351114 - worked well over the prior 3 month cycle, so LESV dilated from 16.5 -
351115 - 18 mm, ref SDS 81 IR57; for some reason triamcinolone injections to
351116 - resist contraction of LESV was not performed. ref SDS 81 IS6L
351118 - ..
351119 - On 120322 1030 EGD dilation procedure - swallowing and vomitting problems
351120 - increased without triamcinolone steriod injections on prior 3 month
351121 - cycle. ref SDS 83 UI9H LESV dilated from 16.5 - 18 mm. ref SDS 83
351122 - 516N Triamcinolone injections to resist contraction of LESV was not
351123 - performed. ref SDS 83 5179
351125 - ..
351126 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA
351127 - business unit; reported patient history. ref SDS 86 RG9K Scheduled
351128 - EGD and dilation procedure for 1300; returned and performed procedure,
351129 - ref SDS 86 TB4J; dilated from 15 mm to 18 mm. ref SDS 86 XB51
351130 - Swallowing and vomitting problems increased after omitting
351131 - triamcinolone steriod injections to resist contraction of LESV after
351132 - dilation, ref SDS 86 TZ4M; therefore, injections were resumed to
351133 - complement dilation to enable and maintain effective swallowing.
351134 - ref SDS 86 R87N
351136 - ..
351137 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found
351138 - improvement recovering from acalasia, LESV contracted only slightly
351139 - from 18 mm down to 15 mm. ref SDS 94 Q333
351141 - ..
351142 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV
351143 - remained at 18 MM, ref SDS 99 CO5N, same as dialated 4 months earlier
351144 - on 130110 0900. ref SDS 94 Q333 Report CT test on 130117, shows
351145 - esophagus fully recovered from severe distortions caused by achalasia
351146 - 8 years earlier. ref SDS 99 MT6F Doctor Lee injected steriod again to
351147 - maintain swallowing. ref SDS 99 F38G Prescribed reducing Omeprazole
351148 - to 1 pill per day. ref SDS 99 R74M Scheduled next EDG dilation in 6
351149 - months, instead of 3. ref SDS 99 6P6G
351151 - ..
351152 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5
351153 - to 18 mm. ref SDS A5 CO5N Triamcinolone steriod injected again to
351154 - maintain improved swallowing. ref SDS A5 I167 Omeprazole medication
351155 - maintained 20 mg taken morning and evening for 1 month, then reduce to
351156 - 20 mg once per day. ref SDS A5 R74M Biopsies taken. ref SDS A5 3N8L
351158 - ..
351159 - On 131121 1604 ordered refill of Omeprazole to aid digestion. There
351160 - is 1 refill remaining. ref SDS A6 YS4O
351162 - ..
351163 - On 131205 1443 received order for Omeprazole prescription placed on
351164 - 131121. ref SDS A7 5N3O
351166 - ..
351167 - On 140318 1043 received letter cancelling meeting scheduled for
351168 - EGD/Dilation procedure on 140425 1000, ref SDS B0 935L; a second
351169 - letter scheduled prodedure on 140509 0900. ref SDS B0 5D7H
351171 - ..
351172 - On 140401 1659 ordered refill Omeprazole; none are remaining; need
351173 - Doctor Lee to order new prescription to increase refills. ref SDS B1
351174 - 4P5M
351176 - ..
351177 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical
351178 - center in Sacramento, Mather. ref SDS B3 K37G Pre-op preperation went
351179 - well - IV setup on first stick. ref SDS B3 EP75 Doctor ordered refills
351180 - for Omeprazole. ref SDS B3 AW5O Doctor patient partnership continues
351181 - to progress with doctor reading up on patient history to be prepared
351182 - for effective meeting. ref SDS B3 ZZ6J Doctor Lee recalled today
351183 - having made timely referral for having heart surgery, enabling patient
351184 - to recover and Half Dome 4 years later. ref SDS B3 0N6I Reported
351185 - swallowing and vomitting problems reduced past 6 months with
351186 - triamcinolone steriod injections to resist contraction of LESV.
351187 - ref SDS B3 VV6N Doctor Lee dilated LESV contracted to only 16.5 MM
351188 - over past 6 months with triamcinolone steriod injections to resist
351189 - contraction; he dilated LESV back to 18 MMy, ref SDS B3 5H5J, scheduled
351190 - next EGD dilation in 6 months since this worked well the past 6 months
351191 - with triamcinolone steriod injections. ref SDS B3 549I The doctor
351192 - explained that since there was no tearing of LESV during procedure
351193 - today, triamcinolone steriod was not injected into LESV to resist
351194 - contraction. ref SDS B3 I167 Progress notes report small tearing of
351195 - LESV during dilation procedure. ref SDS B3 P680
351197 - ..
351198 - On 140718 1017 planning for notifying VA to update current fill date
351199 - for Omeprazole. ref SDS B7 U88L Kathy visited VA in Sacramento, and
351200 - requested changing refill date for Omeprazole to 140718. ref SDS B7
351201 - OL5K VA representative called customer, and said Doctor Lee would
351202 - call back later that day to consider action on updating scheduled
351203 - refill date of Omeprazole to 140718. ref SDS B7 U76M
351205 - ..
351206 - On 140810 1839 letter to Doctor Lee requesting EGD dilation with
351207 - triamcinolone injection soonest, if cancellation occurs; but, not an
351208 - emergency, ref SDS B9 W83K, based on history rising vomitting
351209 - swallowing problems, shown in patient history case study on 120101,
351210 - beginning 140712. ref SDS 82 4E4M
351212 - ..
351213 - On 140819 0800 during meeting at VA Primary Care Clinic in Martinez,
351214 - Doctor Sandhu indicated Doctor Lee at VA Medical Center in Sacramento
351215 - will be notified about rising achalasia symptoms for consideration to
351216 - advance EGD dilation procedure. ref SDS C0 EX78
351218 - ..
351219 - On 141014 0943 Kathy visited VA Medical Center in Sacramento and met
351220 - with Lapria again, who advised that the VA responded in a letter on
351221 - 141001, to the letter on 140810, and further scheduled a meeting with
351222 - Doctor Lee on 141121 1530. ref SDS C1 QJ5N
351224 - ..
351225 - On 141103 2152 submitted agenda for meeting with Doctor Lee at VA
351226 - Sacramento Medical Center on 141107 0800, for next EGD dilation.
351227 - ref SDS C2 K37G Submit record showing normal swallowing occurs longer
351228 - with triamcinolone steriod injection to resist contraction of LESV.
351229 - ref SDS C2 3U97 Request schedule next EGD dilation in 4 months, and
351230 - if LESV does not contract, then schedule following EGD dilation in 6
351231 - months. ref SDS C2 3U66 Notified results of Half Dome hike.
351232 - ref SDS C2 3U6Y
351234 - ..
351235 - On 141107 0800 EGD dilation LESV from 15mm because triamcinalone
351236 - steriod was not injected during prior procedure on 140509. ref SDS C3
351237 - T55I
351239 - ..
351240 - On 150319 0800 meeting Doctor Lee in GI Clinic VA Medical Center
351241 - Sacramento report swallowing improved with triamcinalone steriod
351242 - injections on 141107 EGD dilation procedure. ref SDS C8 0M6I Doctor
351243 - Lee advised that increased orange juice consumption aids digestion,
351244 - and presents no health risks. ref SDS C8 YF5M Scheduled next EGD
351245 - dilation procedure on 150421 1300. ref SDS C8 PS4O Fundoplication
351246 - failure increases acid burn that caused ulceration with hiatal hernia
351247 - with increased recurrance achalasia. ref SDS C8 O56O Doctor Lee will
351248 - make referral to Doctor Stewart at General Surgery VA Medical Center
351249 - in San Francisco for consideration of "redo" fundaplicaiton.
351250 - ref SDS C8 JQ5J Doctor Lee completed Progress Notes for EGD dilation
351251 - on 141107. ref SDS C8 PS53 Doctor Lee will recommend Doctor Stewart
351252 - order CT test to evaluate recurrance achalasia due to failure
351253 - fundoplication. ref SDS C8 TH5M This test can include coronary CTA to
351254 - evaluate regression atherosclerosis. ref SDS C8 GB56
351256 - ..
351257 - On 150420 1752 submitted letter to Doctor Lee with agenda for meeting
351258 - the next day on 150421 1300 for EGD dilation. ref SDS D0 0M6I
351259 -
351260 -
351261 -
351262 -
351263 -
351265 - ..
3513 -
3514 -
3515 - Progress
351601 - ..
351602 - Work Plan Redo Fundoplication and Correct Hiatal Hernia
351603 - Fundoplication Repair to Resolve Hiatal Hernia Ulceration
351604 -
351605 - Follow up ref SDS D3 NU8L, ref SDS D2 NU8L.
351606 -
351607 - Agenda letter for the meeting today was submitted to the medical team
351608 - on 150611 1014. ref SDS D7 2G6K
351610 - ..
351611 - Met first with Graciela Sanabria who reviewed background. She then
351612 - left the room and about 20 minutes later returned with Doctor
351613 - Stewart, who then conducted the meeting.
351614 -
351615 - 1. Initially, reviewed background on Dor fundoplication
351616 - constructed by Doctor Stewart during Heller Myotomy surgery on
351617 - 091216, 091216 0600, ref SDS 36 KE9U, as explained in Progress
351618 - Notes for patient consent a few weeks earlier on 091208...
351619 -
351620 - Using a laparoscope (telescope with a small camera
351621 - attached), rebuilding of the muscle that lies at the base
351622 - of the esophagus to prevent acid from washing back into the
351623 - esophagus, with possible repair of hiatal hernia
351624 - (tightening of the esophageal opening of the diaphragm with
351625 - stitches or staples) and possible need to lengthen
351626 - esophagus with stapling of upper stomach. (collis
351627 - gastroplasty)(laparoscopic fundoplication)
351628 -
351629 - ...and as shown in the record on 100928 0706. ref SDS 56 B04R
351631 - ..
351632 - On 150319, Doctor Lee advised that fundoplication has unraveled
351633 - shown in photograph #4 taken during EGD dilation on 141107,
351634 - listed in Progress Notes. ref SDS C3 H19J The doctor advised
351635 - that Findings of "ulceration" and "Hiatal hernia" in Progress
351636 - Notes on 140509, ref SDS B3 P396, correlates with failure of
351637 - fundoplication, as set out in Impressions from Progress Notes
351638 - on 140509 0900. ref SDS B3 I93F
351640 - ..
351641 - 2. Photographs showing progressive failure Dor fundoplication
351642 - presented on patient notebook computer, c16, received from VAMC
351643 - in Sacramento (Mather), reported in the record on 150616 1624.
351644 - ref SDS D8 XW6M
351646 - ..
351647 - During the meeting today, Doctor Stewart reviewed photograph from EGD
351648 - dilation on 131115...
351649 -
351650 - F:\05\00003\SM\CC\AGMJ\20131115-080024\Welch_11-22-13-photograph.docx
351652 - ..
351653 - This photograph on 131115, shows fundoplication fully intact with
351654 - significant and folding stomach tissue with uniform swirl that aligns
351655 - with patient consent for fundoplication to "prevent acid from washing
351656 - back into the esophagus," which Doctor Stewart constructed during
351657 - Heller Myotomy surgery 4 years earlier on 091216, per above.
351658 - ref SDS 0 626F At that time, Doctor Stewart Progress Notes described
351659 - this surgery thus...
351661 - ..
351662 - We then performed a Dor myotomy starting on the left side.
351663 - The fundus was approximated to the left crus and then the
351664 - left edge of the myotomy using three interrupted 2-0
351665 - Surgidac EndoStitches. We then applied to seal glue over
351666 - the enterotomy and along the myotomy. We then completed
351667 - the right side of the fundoplication by bringing the edge
351668 - of the fundus back over towards the right crus and re-
351669 - approximating the fundus to the right edge of the myotomy
351670 - and then the right crus using three interrupted 2-0
351671 - Surgidac. We completed the closure at the apex of this
351672 - fundoplication using a single 2-0 Surgidac and then
351673 - extended the inferior portion of the right side of the
351674 - fundoplication using another suture of the fundus to the
351675 - right crus alone. We then carefully irrigated and
351676 - suctioned the left upper quadrant around the area of the
351677 - spleen where there was a small amount of spillage. We also
351678 - irrigated over the caudate lobe. ref DRP 1 VK8F
351680 - ..
351681 - Today, Doctor Stewart examined photograph taken by Doctor Lee 6 months
351682 - after EGD dilation on 131115, and taken during the next EGD dilation
351683 - on 140509...
351684 -
351685 - F:\05\00003\SM\CC\AGMJ\20140509-090000\welch-09.pdf
351687 - ..
351688 - Doctor Lee Progress Notes for EGD dilation on 140509, report
351689 - appearance of hiatal hernia suggests fundoplication appears to be
351690 - unraveling. ref SDS B3 I93F Progress Notes on 140509, further report
351691 - ulceration of LESV. ref SDS B3 HG8N Since purpose of Dor
351692 - fundoplication performed on 091216, to prevent reflux from washing
351693 - back from the stomach into the espphagus, shown in Doctor Stewart's
351694 - Progress Notes, per above, ref SDS 0 626F, the presence of ulceration
351695 - on LESV aligns with appearance that fundoplication may be unraveling.
351697 - ..
351698 - Doctor Stewart examined another photograph from EGD dilation 6 months
351699 - later on 141107...
351700 -
351701 - F:\05\00003\SM\CC\AGMJ\20141107-080000\EGD-11_07_2014-10_19-04-photograph.pdf
351703 - ..
351704 - This photograph shows prior significantly and uniform folded and
351705 - ravelled stomach tissue seen a year earlier on 131115, now appears
351706 - with less folds over 50% of the same area, thus unravelling observed
351707 - on 140509, has progressed to noticably flatter geography than the
351708 - prior significantly folded tissue in the photograph taken a year
351709 - earlier on 131115, per above. ref SDS 0 033H
351711 - ..
351712 - Doctor Stewart finally examined photograph from the most recent EGD
351713 - dilation on 150421...
351714 -
351715 - F:\05\00003\SM\CC\AGMJ\20150421-130000\welch-02.pdf
351717 - ..
351718 - This photograph shows Dor fundoplication progressively flatter than on
351719 - 131115, with further unravelling since prior condition 6 months
351720 - earlier on 141107. ref SDS 0 6H5X
351722 - ..
351723 - Doctor Stewart advised during the meeting today, that these
351724 - photographs showing evident significant change in Dor fundoplication
351725 - also indicate fundoplication remains in some manner. She feels the
351726 - angle of the camera taking photographs during EGD dilation procedures,
351727 - and examined today, cannot establish Dor fundoplication has completely
351728 - failed.
351729 -
351731 - ..
351732 - 3. CT barrium swallow test evaluate esophagus performed on 150527
351733 - 0930, ref SDS D4 V56N, implementing Doctor Stewart's order on
351734 - 150526 1300. ref SDS D3 MF8H
351736 - ..
351737 - Previously, on 130122 Doctor Stewart was pleased CT test showed
351738 - esophagus had fully recovered from past distortion caused by
351739 - achalasia, ref SDS 96 VL7N, following Heller Myotomy surgery and
351740 - repeated dilations showing variations in LESV contractions based on
351741 - injections of triamcinalone steriods...
351742 -
351743 - LESV Dilated
351744 - Date from - to
351745 - 150421 16.5 18.....triamcinolone.... ref SDS D1 I167
351746 - 141107 15 18.....triamcinolone.... ref SDS C3 I167
351747 - 140509 16.5 18...................... ref SDS B3 P680
351748 - 131115 16.5 18.....triamcinolone.... ref SDS A5 RZ45
351749 - 130416 18 18.....triamcinolone.... ref SDS 99 Y850
351750 - 130110 15 18.....triamcinolone.... ref SDS 94 Q333
351751 - 120925 15 18.....triamcinolone.... ref SDS 86 XB51
351752 - 120322 16.5 18...................... ref SDS 83 516N
351753 - 111115 16.5 18...................... ref SDS 81 IR57
351754 - 110819 15 16.5...triamcinolone.... ref SDS 80 J978
351755 - 110429 13 16.5...triamcinolone.... ref SDS 75 U23I
351756 - 110218 11 14.....triamcinolone.... ref SDS 71 AA5O
351757 - 101210 11 14...................... ref SDS 67 H347
351758 - 100827 11 15...................... ref SDS 55 JE6X
351759 - 100305 11 15...................... ref SDS 48 WR6L
351761 - ..
351762 - During the meeting today, Doctor Stewart used the computer in the
351763 - office to examine radiology imaging from the CT Barium swallow test on
351764 - 150527. ref SDS D4 OZ3M These files are stored in patient records for
351765 - access in this SDS record at...
351766 -
351767 - F:\05\00003\SM\CC\AGMJ\20150527-092128\ct_barium_swallow_imaging\GEARView.exe
351768 -
351769 - F:\05\00441\SM\BGMC\20150527-092128\ct_barium_swallow_imaging\GEARView.exe
351771 - ..
351772 - Doctor Stewart concurred with Doctor Mulligan's interpretation,
351773 - verified by Doctor Webb, finding...
351774 -
351775 - 1. Interval improvement in dilation of the distal
351776 - esophagus with tapering to the gastroesophageal
351777 - junction. Additional interval improvement in narrowing
351778 - at the gastroesophageal junction - compared to prior CT
351779 - barium swallow test performed at VAMCSF on 121113.
351780 - ref SDS D4 PO4G
351782 - ..
351783 - 2. No significant delay in esophageal emptying into the
351784 - stomach. ref SDS D4 FU3I
351786 - ..
351787 - 3. Mild spontaneous gastroesophageal reflux was observed
351788 - with provocative maneuvers. ref SDS D4 FU37
351790 - ..
351791 - [...below on 150623 1300 gastric emptying test presents
351792 - conflicting results finding no evidence of gastroesophageal
351793 - reflux, possibly reflecting minimal amount of food consumed
351794 - for the test, compared with daily diet for breakfast, lunch
351795 - and/or dinner. ref SDS 0 KX4G
351797 - ..
351798 - Finding "reflux" occurred with this controlled and limited swallowing
351799 - test today may indicate heightened risk for ulceration of LESV with
351800 - acid washing back into the esophagus during normal consumption of food
351801 - and liquid. Fundoplication was performed to prevent acid washing back
351802 - into the esophagus, reported on 091216, shown on 100928 0706.
351803 - ref SDS 56 2W4H If surgery presents risks of damaging adjacent
351804 - tissue, this should be weighed agains risk of damaging endothelium
351805 - lining of blood vessels taking PPI (Omeprazole) medication, which
351806 - recent study found correlates with increased risk of myocardial
351807 - infarction, reported on 150611 0713. ref SDS D6 ZB96
351809 - ..
351810 - Doctor Stewart indicated favorable patient outcomes to date, reflect
351811 - good care by Doctor Lee in GI Clinic at VA Medical Center in
351812 - Sacramento, supplementing favorable results from Heller Myotomy
351813 - surgery with Dor fundoplication on 091216, as originally planned
351814 - during a meeting with Doctor Stewart at the VA Medical Center in San
351815 - Francisco on 091030 0810. ref SDS 24 GM5I
351816 -
351817 - [...below on 150623 1300 VA Progress Notes addendum entered
351818 - by Doctor Stewart commends good job by Doctor Lee at GI
351819 - Clinic VA Medical Center in Sacramento, performing EGD
351820 - dilations to maintain swallowing function. ref SDS 0 SO4J
351822 - ..
351823 - Following up discussions in prior meeting on 150526 1300, ref SDS D3
351824 - 5Y4I, there was further discussion of Doctor Lee's Progress Notes on
351825 - EGD Dilation where examination showed prior ulceration has reduced to
351826 - mere errosion, reported on 150421 1210. ref SDS D1 PXXY Since this
351827 - improvement occurred after patient independently increased dose of PPI
351828 - from 20 mg twice per day to occasionally taking 20 mg 3 times and even
351829 - 4 times per day, the problem of failed Dor fundoplication causing
351830 - ulceration of LESV might be resolved by simply increasing PPI daily
351831 - dose to 40 mg twice per day.
351833 - ..
351834 - Doctor Stewart further proposed supplementing Omeprazole PPI with
351835 - treament using Famotidine 20 mg "H2 Blocker." We reviewed work plan
351836 - to present this treatment change to Doctor Lee, maintaining continuity
351837 - of care for achalasia, which Doctor Lee has provided the past 10
351838 - years. Doctor Stewart concurred. She ordered an initial Famotidine
351839 - 20 mg H2 Blocker prescription, and requested that Doctor Lee be
351840 - notified for timely review and approval.
351842 - ..
351843 - After the meeting, research on Internet found...
351844 -
351845 - 1. Wikipedia...
351846 -
351847 - https://en.wikipedia.org/wiki/Famotidine
351849 - ..
351850 - Famotidine (trade name Pepcid) is a histamine H2-receptor
351851 - antagonist that inhibits stomach acid production. It is
351852 - commonly used in the treatment of peptic ulcer disease and
351853 - gastroesophageal reflux disease. Unlike cimetidine, the first
351854 - H2 antagonist, famotidine has no effect on the cytochrome P450
351855 - enzyme system, and does not appear to interact with other
351856 - drugs.
351857 -
351858 - 1. Uses...
351859 -
351860 - Relief of heartburn, acid indigestion, and sour stomach
351862 - ..
351863 - Treatment for Gastroesophageal reflux (GERD)
351865 - ..
351866 - Treatment for Esophagitis
351868 - ..
351869 - Part of a multidrug regimen for H. pylori eradication,
351870 - although omeprazole may be somewhat more effective.
351872 - ..
351873 - 2. Side effects associated with famotidine use include
351874 - headache, dizziness, and constipation or diarrhea.
351876 - ..
351877 - Another source....
351878 -
351879 - 2. Medline Plus
351880 -
351881 - 1. These medicines (H2 Blockers) are most often taken with the
351882 - first meal of the day. In some cases, you may also take
351883 - them before your evening meal.
351885 - ..
351886 - 2. It takes 30 to 90 minutes for the medicines to work. The
351887 - benefits will last several hours. People often take the
351888 - drugs at bedtime, as well.
351890 - ..
351891 - [On 150624 0924 letter notified Doctor Lee of work plan to
351892 - try controlling ulceration of LESV by increasing PPI with
351893 - Omeprazole rather than chance performing high risk surgery
351894 - to repair Dor fundoplication, and that Doctor Stewart
351895 - ordered H2 Blocker for Doctor Lee to consider supplementing
351896 - PPI to control acid reflux. ref SDS D9 OP91
351898 - ..
351899 - [On 150624 0924 at 1344 Doctor Lee called and will order
351900 - new prescription for PPI increasing Omeprazole from 20
351901 - mg twice per day to 40 mg twice per day. ref SDS D9 L861
351903 - ..
351904 - [On 150925 0336 request switch back to Omeprazole 20 mg
351905 - twice per day in order to reduce severe side effects of
351906 - dehydration from frequent urination causing scaling,
351907 - peeling, bleeding feet; lower dose Omeprazole enables
351908 - hiking to raise HDL required to regress atherosclerosis
351909 - plaques, thereby lowering risks of CVD and CAD.
351910 - ref SDS E4 5G8T As a result, Pharmacy VA Medical Center
351911 - San Francisco entered new prescription for (PPI)
351912 - Omeprazole 20 mg. ref SDS E4 FK66
351914 - ..
351915 - [On 151002 1820 Doctor Lee returned call; will order
351916 - Omeprazole 20 mg prescription sufficient until next EGD
351917 - Dilation procedure on 151204, and complimenting
351918 - prescription entered on 150925 for only 1 month.
351919 - ref SDS E6 NV5I
351921 - ..
351922 - [On 140101 0600 took first H2 Blocker medication to
351923 - resolve stomach pain level 6 after taking Omeprazole,
351924 - and to avoid taking another Omeprazole in order to avoid
351925 - side effects. ref SDS A9 KG5O
351927 - ..
351928 - Analysis by Doctor Mulligan and Doctor Webb, finding CT barrium
351929 - swallow test performed on 150527 further shows...
351930 -
351931 - 4. No hiatal hernia was identified. ref SDS D4 V16O
351933 - ..
351934 - Nothing in the record reconciles finding "no hiatal hernia" during CT
351935 - barium swallow test on 150527, compared to finding hiatal hernia
351936 - during direct examination shown in Progress Notes on 140509.
351937 - ref SDS B3 P34O, again on 141115, ref SDS C3 QD6O, and in most recent
351938 - EGD dilation on 150421. ref SDS D1 QD6O
351940 - ..
351941 - Doctor Stewart was pleased these findings align with test results on
351942 - 130117, which she reviewed favorably on 130122 1330. ref SDS 96 VL7N
351944 - ..
351945 - At this time, it is not clear in the record how findings from the
351946 - recent CT test on 150527 compares with the test on 130117, because
351947 - Radiology Department did not make this comparison when notified during
351948 - the test on 150527. ref SDS D4 UV6O
351949 -
351951 - ..
351952 - 3. Gastric Emptying Test favorable results on 150603 0800.
351953 - ref SDS D5 K37G
351955 - ..
351956 - Doctor Stewart was pleased this additional test found normal digestion
351957 - function, ref SDS D5 LC5F, including...
351958 -
351959 - ...no evidence for gastroesophageal reflux. No
351960 - significant amount of activity is noted in the distal
351961 - esophagus. ref SDS D5 G25L
351963 - ..
351964 - This appears conflicting with CT Barium Swallow test finding "mild
351965 - spontaneous gastroesophageal reflux observed", reported above.
351966 - ref SDS 0 2W7F
351968 - ..
351969 - Eating part of an egg in the Gastric Emptying Test likely produces
351970 - significantly less reflux than eating normal breakfast of 2 egg
351971 - omelette - cheese, sausage, onion asparagus mushrooms, toast; or
351972 - normal lunch - sandwich ham cheese, chips, shown in patient history,
351973 - e.g., beginning on 150624, shown in case study on 140101 0600.
351974 - ref SDS A8 QC7H
351975 -
351976 -
351978 - ..
351979 - 4. Coronary CT angiography (CCTA) test with calcium score will
351980 - assess patient tolerance for PPI (Omeprazole) to complement
351981 - changing fundoplication shown in EGD dilation photographs, per
351982 - above, ref SDS 0 3C5I, maintaining continuity to prevent acid
351983 - washing back into the esophagus and causing ulceration and
351984 - hitatal hernia at GE junction, also discussed above.
351985 - ref SDS 0 3E4I
351987 - ..
351988 - Doctor Stewart said she is aware of risks presented by PPI
351989 - (Omeprazole) treatments, and supports performing coronary CT
351990 - angiography testing to verify patient tolerance for PPI treatment to
351991 - prevent acid washing back into the esophagus.
351993 - ..
351994 - CT of chest can further test response to treatment for recovery
351995 - from CVD, based on 5 years hiking 11 miles per day that raised
351996 - HDL 30 to HDL 70, shown in patient history...
351997 -
351998 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
352000 - ..
352001 - Background showing coronary CTA standard of care evaluate post
352002 - CABG, shown in Progress Notes on 140519 0800. ref SDS B4 OF7N
352004 - ..
352005 - Doctor Stewart asked about side effects of statins in this case.
352006 -
352007 - [...below on 150623 1300 Doctor Stewart entered addendum to
352008 - Progress Notes saying she supports performing CCTA and
352009 - defers to Primary Care to order the test. ref SDS 0 UM4O
352010 -
352011 - [On 150701 1057 letter to Isagani asking Doctor Stewart to
352012 - enter addendum to Progress Notes with explanation of
352013 - reasons as follows...
352014 -
352015 - "Coronary CTA will assess patient tolerance for continuing PPI
352016 - treatment to prevent acid washing back into the esophagus,
352017 - supplementing Dor fundoplication that avoids ulceration of
352018 - LESV, which began occurring in this case reported in Doctor
352019 - Lee's Progress Notes for EGD dilatations on 140509, again on
352020 - 141107, and most recently on 150421. CCTA to assess tolerance
352021 - for PPI is indicated by recent massive study published just 3
352022 - weeks ago on 150610, correlating PPI with increased risk of
352023 - myocardial infarction, and cites damage to endothelial lining
352024 - of blood vessels. If CCTA shows this patient is not at risk,
352025 - then PPI can continue to provide improved swallowing."
352026 -
352027 - ...for ordering CCTA. ref SDS E1 NU8L
352029 - ..
352030 - [On 150925 0336 meeting with Doctor Stewart in Med Surg
352031 - patient area; explained delays ordering CCTA; the doctor
352032 - will consider ordering CCTA to assess prospects for
352033 - avoiding side effects, and after submitting for patient
352034 - review and response articles on side effects of statin
352035 - drugs. ref SDS E5 SD9O
352037 - ..
352038 - [On 151005 1102 discussion with Doctor Wisneski in
352039 - Cardiology; she proposed reducing dose of statins and
352040 - taking treatment every other day, to reduce adverse side
352041 - effects. ref SDS E7 GL7G
352043 - ..
352044 - Explained history of...
352045 -
352046 - 1. Myopathy - muscle pain raising left shoulder above
352047 - horizontal taking Simvastatin.
352048 -
352049 - 2. Peripheral neuropathy both feet.
352051 - ..
352052 - 3. Dizziness
352054 - ..
352055 - 4. Urination increased frequency due to liver damage from
352056 - treatment with statin drugs, causing dehydration - cannot
352057 - open mouth, feet cracking, bleeding. (reported on 150311 in
352058 - case study on 140101 0600. ref SDS A8 XZ7M
352060 - ..
352061 - Had to pause Atorvastatin treatment on 150427, also shown
352062 - in case study on 140101 0600. ref SDS A8 AS5J
352064 - ..
352065 - On 150516 resumed Atorvastatin and Ezetimibe protocol
352066 - shown in case study on 140101. ref SDS A9 P84G
352068 - ..
352069 - [On 150809, frequent urination resumed causing dehydration
352070 - injuries to feet again, so paused Atorvastatin and
352071 - Ezetimibe, shown in case study on 140101. ref SDS A9 GH3G
352073 - ..
352074 - [On 150819 continuing blisters on side of big toes due to
352075 - dehydration, despite pausing statin treatments, also paused
352076 - Proton Pump Inhibitor (PPI - Omeprazole), because research
352077 - found taking PPI 80 mg previously caused signficant
352078 - dehydration, also reported in case study on 140101.
352079 - ref SDS A9 X07H
352081 - ..
352082 - Favorable CCTA might support reducing reliance on statin drugs.
352083 -
352084 -
352085 -
352086 -
352087 -
352088 -
3521 -
SUBJECTS
Default Null Subject Account for Blank Record
3603 -
360401 - ..
360402 - Medical Chart Progress Notes Doctor Stewart General Surgery Meeting 150623
360403 -
360404 - Follow up ref SDS D3 954J, ref SDS 96 PH8J.
360406 - ..
360407 - VA prescription refill website is at...
360408 -
360409 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
360411 - ..
360412 - Customer....
360417 - ..
360418 - Received Progress Notes for meeting on 150526 and stored in...
360419 -
360420 - F:\05\00003\SM\CC\AGMJ\20150623-130000\My HealtheVet_portal.txt
360421 -
360422 - F:\05\00441\SM\BGMC\20150623-130000\My HealtheVet_portal.txt
360424 - ..
360425 - 1. Date/Time: 24 Jun 2015 @ 1541
360426 - Note Title: GENERAL SURGERY CLINIC
360427 - Location: SAN FRANCISCO VAMC
360428 - Signed By: SANABRIA,GRACIELA ELENA
360429 - Co-signed By: SANABRIA,GRACIELA ELENA
360430 - Date/Time Signed: 24 Jun 2015 @ 1615
360432 - ..
360433 - LOCAL TITLE: GENERAL SURGERY CLINIC
360434 - STANDARD TITLE: SURGERY OUTPATIENT NOTE
360435 - DATE OF NOTE: JUN 24, 2015@15:41 ENTRY DATE: JUN 24, 2015@15:41:14
360436 - AUTHOR: SANABRIA,GRACIELA E EXP COSIGNER:
360437 - URGENCY: STATUS: COMPLETED
360439 - ..
360440 - These Progress Notes fail to state the date and time of the meeting on
360441 - 150623, and instead convey false impression the meeting was on 150624.
360442 -
360443 - [...below on 150623 1300 Progess Notes state "He is here
360444 - today..." ref SDS 0 IC6F
360445 -
360446 - [On 150701 1057 letter notified medical team of conflict
360447 - between Progress Notes failing to accurately reports date
360448 - of events. ref SDS E0 K66I
360450 - ..
360451 - Graciela Sanabria is Doctor Stewart's physician assistant, who
360452 - conducted the initial interview, and then briefed the doctor. She
360453 - attended the meeting with Doctor Stewart, reported per above.
360454 - ref SDS 0 K37G
360455 -
360456 -
360457 - *** GENERAL SURGERY CLINIC Has ADDENDA ***
360459 - ..
360460 - 2. S: 70 yo male who underwent Laparoscopic Heller myotomy and Dor
360461 - fundoplication in 2009 for achalasia.
360463 - ..
360464 - Heller myotomy surgery was performed by Doctor Stewart at the VA
360465 - Medical Center in San Francisco on 091216, shown by Progress Notes
360466 - entered in the record on 100928 0706. ref SDS 56 125W
360468 - ..
360469 - Dor fundoplication was performed during the same procedure,
360470 - ref SDS 56 VK8F, for the purpose of preventing acid from washing back
360471 - into the esophagus, with possible repair of hiatal hernia. ref SDS 56
360472 - 2W4H
360474 - ..
360475 - Progress Notes continue...
360476 -
360477 - Postoperatively patient developed a stricture and has been
360478 - receiving esophageal dilations and steroid injections to assist
360479 - with his dysphagia. Patient's ability to swallow has improved
360480 - with these treatments and treatments have been able to be
360481 - spaced from q3-4 months to q6 months. Patient has followed up
360482 - with his GI physician. A hital hernia and loosing of the
360483 - fundoplication was appreciated on recent EGD in April 2015.
360485 - ..
360486 - Change "loosing" to "loosening".
360488 - ..
360489 - Begin with precisely what the record shows on specific dates, so there
360490 - is continuity understanding work history.
360492 - ..
360493 - VA Progress Notes for EGD dilation procedure on 140509, report shallow
360494 - ulceration at GE junction, ref SDS B3 HG8N; hiatal hernia identified,
360495 - ref SDS B3 P34O; hiatal hernia suggests fundoplication appears to be
360496 - loosening. ref SDS B3 I93F Recommend increase proton pump inhibitor
360497 - to prevent ulceration. ref SDS B3 PXXY
360499 - ..
360500 - VA Progress Notes for EGD dilation on 141107, report continued
360501 - ulceration and hiatal hernia, ref SDS C3 MG6N, and recommended
360502 - continued proton pump inhibitor to reduce esophageal stricture
360503 - reformation. ref SDS C3 JL4F
360505 - ..
360506 - VA Progress Notes for EGD dilation on 150421, report hiatal hernia
360507 - visible, ref SDS D1 QD6O; Gastroesophageal reflux stricture not
360508 - reforming as rapidly. Previous ulcerations appear to be regressing,
360509 - although slowly, as these are now more erosions rather than
360510 - ulcerations. ref SDS D1 PXXY
360512 - ..
360513 - Ulcerations regressing aligns with patient increasing proton pump
360514 - inhibitor (Omeprazole), reported to Doctor Lee during EGD dilation on
360515 - 150421 1210, ref SDS D1 1J3K, and cited in the letter for Doctor
360516 - Stewart on 150611 1014. ref SDS D7 SG9Q
360518 - ..
360519 - Progress Notes continue...
360520 -
360521 - Patient followed up in Gen Surg clinic on May 2015 to discuss
360522 - surgical options to redo his fundoplication.
360524 - ..
360525 - Patient met with Doctor Stewart on 150526, to redo fundoplication for
360526 - preventing backflow of acid into the esophagus shown by ulceration of
360527 - LESV and increased burping. ref SDS D3 K37G
360529 - ..
360530 - Progress Notes continue...
360531 -
360532 - Surgery patient was not recommended at the time due to patient
360533 - showing improvement in his swallowing and Barium swallow
360534 - studying showing: improvement in the esophageal dilatation and
360535 - no hiatal hernia. However it was recommended that patient
360536 - obtain a gastric emptying study to further evaluate.
360538 - ..
360539 - He is here today to review the results of this study.
360541 - ..
360542 - This conflicts with Progress Notes dated the next day on 150624, per
360543 - above. ref SDS 0 6A5M
360544 -
360545 - [On 150701 1057 letter notified medical team of conflict
360546 - between Progress Notes failing to accurately reports date
360547 - of events. ref SDS E0 K66I
360549 - ..
360550 - Barium swallow test was ordered by the doctor on 150526, to aid
360551 - diagnosis. ref SDS D3 MF8H It was performed the next day on 150527.
360552 - ref SDS D4 V56N
360554 - ..
360555 - Purpose of the meeting on 150623, was to show Doctor Stewart
360556 - photographs of progressive changes in Dor fundoplication, and
360557 - ulceration of LESV, which she was unable to see on VA computer system
360558 - due to slow access during prior meeting on 150526, ref SDS 0 QJ6O, so
360559 - there is common understanding on patient status experiencing acid
360560 - washing back into the esophagus, shown by symptoms of ulceration on
360561 - LESV and increased burping, which Dor fundoplication was intended to
360562 - prevent. ref SDS 0 K37G Secondarily, the meeting on 150623,
360563 - considered solutions, including trade-offs between surgical repair and
360564 - increasing proton pump inhibitor (Omeprazole).
360566 - ..
360567 - Progress Notes continue...
360568 -
360569 - Currently patient states that he does have increased burping.
360570 - He does continue to have regurgitation and vomiting at times
360571 - but feels that this has improved. Patient is able to eat
360572 - salmon and continues to drink juices and soda. He is taking
360573 - Omeprazole and has increased to taking it three times per day.
360575 - ..
360576 - This assists with his symptoms. However he is concerned if
360577 - this is affecting his blood vessels and would like to get to a
360578 - cornary CTA to evaluate.
360580 - ..
360581 - Patient presented evidence of very recent medical study published on
360582 - 150610, by Houston Methodist and Stanford University scientists, and
360583 - shown in the record on 150611, finding patients taking proton pump
360584 - inhibitor (PPI) drugs (here Omeprazole) have 16% - 21% increased risk
360585 - of myocardial infarction (heart attack), ref SDS D6 5N3O, from adverse
360586 - effects to endothelium lining of blood vessels. ref SDS D6 VC5O This
360587 - evidence was submitted to the medical team in a letter later that day
360588 - on 150611 1014. ref SDS D7 SG82
360589 -
360591 - ..
360592 - 3. O: Vital Signs:
360593 - Height: 66 in [167.6 cm] (12/16/2009 18:00)
360594 - Weight: 186.1 lb [84.6 kg] (06/23/2015 14:42)
360595 - BMI: 30.1 (Obesity Level I)
360596 - BP: 136/72 (06/23/2015 14:42)
360597 - Resp: 20 (08/28/2014 08:36)
360598 - Pulse: 94 (06/23/2015 14:42)
360599 - O2 Sat: 6/23/15 14:42:09 O299
360600 - Pain: 2 (06/23/2015 14:42)
360602 - ..
360603 - 4. Gen: NAD, sitting in chair
360604 - Resp: nonlabored breathing
360605 - ABd: soft, ND/NT
360607 - ..
360608 - 5. GASTRIC EMPTYING STUDY
360609 -
360610 - Impression:
360611 -
360612 - 1. Normal gastric emptying for solids.
360613 -
360614 - 2. T1/2 gastric emptying time equals 72 min (within
360615 - normal
360616 - limits)
360618 - ..
360619 - 3. There is no evidence for gastroesophageal reflux during
360620 - this study. In particular, no significant activity is
360621 - noted in the distal esophagus to suggest delayed esophageal
360622 - emptying.
360624 - ..
360625 - This section appears to be a quote from Progress Notes for Gastric
360626 - Emptying study on 150603 0800. ref SDS D5 TE6K
360628 - ..
360629 - Progress Notes continue...
360630 -
360631 - 6. A/P: 70 yo male with history of achalasia who underwent
360632 - Laparoscopic Heller myotomy and Dor fundoplication in 2009.
360633 - Patient has been doing well from his surgery with esophageal
360634 - dilations and steroid injections. Patient has been concerned
360635 - about recent findings on EGD that there may be a loosening of
360636 - his fundoplication. Images were reviewed by Dr Stewart who
360637 - believes that fundoplication looks intact. Patient was
360638 - reminded that EGD is not the best modality to evaluate the
360639 - fundoplication. Patient was also reminded that fundo may be
360640 - slightly loosened due to recurrent dilations. Gastric emptying
360641 - study was reviewed. It was explained to patient that re-doing
360642 - the fundoplication puts him a high risk of perforation or leak
360643 - due to all the scar tissue in the area. There is currently no
360644 - indication for sugery therefore risks would outweight any
360645 - benefits.
360647 - ..
360648 - Change "outweight" to outweigh" in last sentence.
360650 - ..
360651 - Progress Notes are not clear on the difference between "S" section
360652 - above, ref SDS 0 273K, and "A/P" in this section. ref SDS 0 EZ3L
360654 - ..
360655 - Previously, Doctor Stewart's Progress Notes have a section "HPI" shown
360656 - for meeting on 150526 1300. ref SDS D3 X45M
360658 - ..
360659 - Representation in the last sentence that "risks would outweigh any
360660 - benefits," requires statement of "benefits" from fundoplication to
360661 - prevent acid from washing back into esophagus causing ulceration of
360662 - LESV, and hiatal hernia, as set out in consent for original surgery on
360663 - 091216, reported in the record on 100928. ref SDS 56 2W4H
360665 - ..
360666 - Patient cited VA Progress Notes report beginning on 140509 that EGD
360667 - dilation procedure found ulceration at GE junction, ref SDS B3 HG8N,
360668 - from acid washing back into the esophagus indicating protection has
360669 - declined with fundoplication planned during surgery on 091216
360670 - (reported in patient records on 100928 0706, ref SDS 56 2W4H, and
360671 - previously presented to evaluate approving Heller Myotomy surgery
360672 - during a meeting with Doctor Stewart on 091030 0810. ref SDS 24 OY64
360673 - This was the reason for requesting referral to Doctor Stewart, shown
360674 - in the letter on 150611, ref SDS D7 SG9Q, submitting the agenda for
360675 - meeting with Doctor Stewart on 150623, and following up discussion
360676 - with the doctor during the earlier meeting on 150526 1300. ref SDS D3
360677 - 3E4I
360679 - ..
360680 - Progress Notes continue...
360681 -
360682 - 7. Recommend that patient continue on PPI. Will start him on H2:
360683 - Pepcid to assist with symptoms of regurgitation
360685 - ..
360686 - 8. will defer to PCP re: coronary CTA, ok from surgical standpoint
360687 - to obtain study
360688 -
360689 - 9. follow-up as needed
360691 - ..
360692 - Progress Notes can aid ordering coronary CTA by explaining this will
360693 - show whether patient can tolerate continuing PPI supplemented with H2
360694 - blocker to prevent acid from washing back into esophagus causing
360695 - ulceration. Investigation for tolerance of continuing PPI aligns with
360696 - report from recent massive study published on 10 June 2015, citing
360697 - correlation between PPI and increased risk of myocardial infarction,
360698 - further associated with damage to endothlium lining of blood vessels,
360699 - as presented to the VA in a letter on 150611.
360701 - ..
360702 - Progress Notes continue...
360703 -
360704 - 10. I have discussed the patient with my attending physician, Dr Stewart,
360705 - who agrees with my assessment and plan.
360707 - ..
360708 - 11. Current medications reviewed with patient/caregiver and
360709 - reconciliation of medications related to today's visit
360710 - completed, including non-VA medications and discrepancies, if
360711 - identified, were addressed. Medication changes and the
360712 - importance of medication management were reviewed with the
360713 - patient/caregiver today based on individual needs.
360714 - Patient/caregiver acknowledged understanding of instructions as
360715 - stated. An updated list of reconciled medications has been
360716 - provided to the patient/caregiver.
360717 -
360718 -
360719 - 12. /es/ GRACIELA ELENA SANABRIA
360720 - PA-C
360721 - Signed: 06/24/2015 16:15
360723 - ..
360724 - 13. Receipt Acknowledged By:
360725 - 06/24/2015 16:40
360726 - /es/ Lygia Stewart, M.D., 2860
360727 - Chief General Surgery, Assoc Chief Surgery
360729 - ..
360730 - 14. 06/24/2015 ADDENDUM STATUS: COMPLETED
360731 -
360732 - There is no indication for surgical intervention, his GI MD is
360733 - doing a great job with dilatation. His gastric emptying study
360734 - was normal.
360736 - ..
360737 - Commending Doctor Lee's work at GI Clinic VA Medical Center Sacramento
360738 - aligns with discussions during the meeting, per above. ref SDS 0 2M6G
360740 - ..
360741 - Progress Notes continue...
360742 -
360743 - I discussed with the patient that the dilatation (which
360744 - improved his swallowing - would loosen the wrap, but the EGD
360745 - looks good to me. In addition, an EGD is not a good method for
360746 - evaluation of a Dor (180 degree) fundoplication. In addition,
360747 - the need for dilatation means that he has a higher tendency to
360748 - form fibrotic scar - this would greatly increase the risk of
360749 - any surgical re-operation - but, importantly, he does not need
360750 - surgery at this time.
360752 - ..
360753 - Doctor Stewart's explanation in Progress Notes today, of elevated risk
360754 - to repair Dor Fundoplication aligns with her prior evaluation that
360755 - adjacent tissue might be injured while attempting this surgery,
360756 - reported during the meeting on 150526 1300. ref SDS D3 L44F She was
360757 - also concerned that laprasonic methods might fail, and require more
360758 - invasive conventional surgery. ref SDS D3 GT5G
360760 - ..
360761 - Progress Notes continue...
360762 -
360763 - 15. He is very interested in having a CT cardiac evaluation. I
360764 - would suppport this - but would have to defer to his primary on
360765 - this.
360767 - ..
360768 - This generally aligns with discussion during the meeting, but should
360769 - be more explicit on the reasons for ordering CCTA, per above.
360770 - ref SDS 0 1Y5L
360771 -
360772 - [On 150701 1057 letter to Isagani asking Doctor Stewart to
360773 - enter addendum to Progress Notes with explanation of
360774 - reasons as follows...
360775 -
360776 - "Coronary CTA will assess patient tolerance for continuing PPI
360777 - treatment to prevent acid washing back into the esophagus,
360778 - supplementing Dor fundoplication that avoids ulceration of
360779 - LESV, which began occurring in this case reported in Doctor
360780 - Lee's Progress Notes for EGD dilatations on 140509, again on
360781 - 141107, and most recently on 150421. CCTA to assess tolerance
360782 - for PPI is indicated by recent massive study published just 3
360783 - weeks ago on 150610, correlating PPI with increased risk of
360784 - myocardial infarction, and cites damage to endothelial lining
360785 - of blood vessels. If CCTA shows this patient is not at risk,
360786 - then PPI can continue to provide improved swallowing."
360787 -
360788 - ...for ordering CCTA. ref SDS E1 NU8L
360790 - ..
360791 - [On 150708 0842 called and talked to Graciella, ref SDS E2
360792 - K37G; she indicated Doctor Stewart will not approve
360793 - proposed addendum because the matter should be considered
360794 - by Primary Care provider. ref SDS E2 MY31 Gracialla will
360795 - submit letter showing she submitted the proposed draft
360796 - addendum to Doctor Stewart, and reporting the Doctor's
360797 - response. ref SDS E2 PE7M
360799 - ..
360800 - [On 150729 0800 Doctor Rao reluctant to order CCTA, because
360801 - Doctor Stewart's Progress Notes supporting CCTA in this
360802 - case, and referring the matter to Primary, does not give
360803 - reasons for ordering this testing regimen. ref SDS E3 TA91
360805 - ..
360806 - [On 150925 0336 meeting with Doctor Stewart in Med Surg
360807 - patient area; explained delays ordering CCTA; the doctor
360808 - will consider ordering CCTA to assess prospects for
360809 - avoiding side effects, and after submitting for patient
360810 - review and response articles on side effects of statin
360811 - drugs. ref SDS E5 SD9O
360813 - ..
360814 - Progress Notes conclude...
360815 -
360816 - 16. /es/ Lygia Stewart, M.D., 2860
360817 - Chief General Surgery, Assoc Chief Surgery
360818 - Signed: 06/24/2015 16:45
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