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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