CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10
2503 -
2503 - ..
2504 - Summary/Objective
2505 -
250501 - Follow up ref SDS F4 0000. ref SDS D4 0000.
250502 -
250503 - Met with Doctor Lee at VA Medical Center in Sacramento (Mather).
250504 - Checking in and initial administration went well. ref SDS 0 GD4H
250505 - Preparation for the procedure was professional; no difficulties
250506 - setting IV for conscious sedation today. ref SDS 0 544G Reported
250507 - right knee pain level 6. ref SDS 0 6P9I Diffuculty swallowing this
250508 - cycle began occurring about 1 month after prior EGD dilation procedure
250509 - on 151204. ref SDS 0 P55L Reported using baking soda to relieve
250510 - reflux, which then prevents ulceration LESV alternative to Omeprazole
250511 - and in order to avoid side effects causing dehydration. ref SDS 0 Z84H
250512 - Progress Notes report there is no longer any associated erosive
250513 - esophagitis and there is no evidence of mass effect. This implies
250514 - better acid suppression compared to the previous examination of
250515 - December 2015. ref SDS 0 PXXY Performing EGD dilation procedure went
250516 - smoothly, with no reports of difficulties. ref SDS 0 7V6I Post
250517 - procedure Doctor Lee reported LESV contracted to 9.5 mm, the smallest
250518 - diameter in patient history, indicating continual effects 2 month
250519 - delay to 8 months performing EGD on 151204, was significantly harmful.
250520 - ref SDS 0 5H5J
250521 -
250522 -
250523 -
250524 -
250525 -
250527 - ..
2506 -
2507 -
2508 - Background
2509 -
250901 - On 050629 meeting Primary Care swallowing and vomitting problems
250902 - reported. ref SDS 1 K78K
250904 - ..
250905 - On 050714 barrium swallow test, ref SDS 2 2I4S, showed esophagus
250906 - distorted by swallowing problems. ref SDS 2 WE4H
250908 - ..
250909 - On 050816 meeting Primary Care Doctor Sandhu diagnoses achalasia.
250910 - ref SDS 3 DG8G Ultrasound test ordered to verify initial diagnosis of
250911 - swallowing and vomitting problems. ref SDS 3 6E7H Primary Care made
250912 - referral to GI clinic for care to resolve swallowing problems.
250913 - ref SDS 3 0G7M
250915 - ..
250916 - On 050830 ultrasound test evaluate swallowing problems possible
250917 - diagnosis achalasia. ref SDS 4 DG8G
250919 - ..
250920 - On 050830 results received barrium swallow test performed on 050714,
250921 - findings in the lower espohagus and gastroesophageal junction are
250922 - consistent with achalasia - recommend endoscopic examination.
250923 - ref SDS 4 6H9S
250925 - ..
250926 - On 050906 report ultrasound test on 050830, finds no cause for
250927 - swallowing problems and does not diagnose achalasia. ref SDS 5 BM6R
250929 - ..
250930 - On 051202 meeting GI Clinic Doctor Lee diagnoses achalasia.
250931 - ref SDS 6 HP9H Orders endoscopy (EGD) test to verify diagnosis of
250932 - achalasia and assess for cancer. ref SDS 6 NZ5H
250934 - ..
250935 - On 051209 GI Clinic endoscopy examination preliminary findings no
250936 - evidence of cancer, ref SDS 7 0001; biopsy report should be submitted
250937 - in a few weeks to confirm status of cancer, ref SDS 7 PY5J, and if so,
250938 - then a procedure can be schedule for next month to dilate the
250939 - exophageal sphincter valve. ref SDS 7 NZ5H
250941 - ..
250942 - On 051222 biopsy reports no evidence of cancer. ref SDS 8 FT6M
250944 - ..
250945 - On 060111 received letter from Doctor Lee in the Gastrointestinal (GI)
250946 - Clinic reporting that the biopsy was negative for cancer and
250947 - infection; next step is manometry test to verify achalasia, then
250948 - treatment for achalasia. ref SDS 9 4Q3R
250950 - ..
250951 - On 060125 manomety test scheduled for 060209 0800. ref SDS 10 GG9I
250953 - ..
250954 - On 060209 meeting at VA Mather AFB in Sacramento, test was postponed
250955 - until 060223, due to equipment failure. ref SDS 11 OW6M
250957 - ..
250958 - On 060221 Jimmy in GI Department at Sacramento VA Medical Center
250959 - reports manometry equipment still broken; has been sent out for
250960 - repairs and there is no date at this time on when the equipment will
250961 - be available for use at the VA. ref SDS 12 ND7M
250963 - ..
250964 - On 060330 endoscopy follow up examination at GI Department Sacramento
250965 - Medical Center - Doctor Lee finds no evidence cancer performed at VA
250966 - Sacramento condition precedent treatment recover from achalasia.
250967 - ref SDS 13 VX4G
250969 - ..
250970 - On 060330 manometry test performed by Doctor Lee at VA in Sacramento,
250971 - ref SDS 13 MC7P, verifies diagnosis swallowing and vomitting problems
250972 - caused by achalasia, ref SDS 13 MD4N, patient meets criteria for
250973 - treatment with pneumatic dilation. ref SDS 13 MD5G
250975 - ..
250976 - On 060505 Martinez VA GI clinic Doctor Lee reported equipment and
250977 - pneumatic balloon materials on hand to perform dilation for treating
250978 - achalasia; treatment delayed until diagnostic data is received from
250979 - Sacramento VA Medical Center from manometry test performed on 060330;
250980 - doctor following up to obtain data; will submit test data to patient
250981 - during the week of 060508, along with a schedule to treat achalasia.
250982 - ref SDS 14 FT6M
250984 - ..
250985 - On 060614 Martinez VA GI clinic reports increased work load treating
250986 - soldiers returning from war in Iraq requires prioritizing; patient
250987 - advocate, Rubin Soto, will coordinate with the GI Clinic notifying the
250988 - customer of the schedule based on current priorities. ref SDS 15 J86N
250990 - ..
250991 - On 070220 letter to VA asks about progress getting test results from
250992 - VA in Sacramento, and scheduling surgery for achalasia, ref SDS 16
250993 - 5R5R
250995 - ..
250996 - On 090812 1030 continued vomitting achalasia causes weight loss 30
250997 - pounds in a few months, Primary Care physician notified GI clinic to
250998 - review schedule for dilation to relieve achalasia. ref SDS 17 7L5O
251000 - ..
251001 - On 090908 meeting GI Clinic in Martinez reports treatment for
251002 - achalasia still waiting to receive results for manometry test on
251003 - 060330, at Sacramento VA Medical Center. ref SDS 18 HX46 Prepared new
251004 - work plan to treat achalasia without manometry test results, because
251005 - the doctor performed the test 3 years ago, and is so knows results
251006 - consistent with achalasia, shown on 060330 0712, ref SDS 13 MD4N;
251007 - schedules treatment for achalasia after treadmill stress test,
251008 - ref SDS 18 BU6W, to evaluate new chest pains hiking hills at Lafayette
251009 - Reservoir which have not occurred doing extended exercise hiking 3 -
251010 - 14 miles a day over the past 5 years. ref SDS 18 MY4N
251012 - ..
251013 - On 091021 report history achalasia issue during meeting with
251014 - cardiothoracic surgery team to prepare for heart bypass surgery the
251015 - next day. ref SDS 20 NX6M Surgery team will coordinate with
251016 - anesthesia team to provide swallowing relief during heart surgery to
251017 - prevent choking. ref SDS 20 R78O
251019 - ..
251020 - On 091022 0700 meeting anesthesia team - Doctor Brezinski not familiar
251021 - with achalasia - asked if achalasia has been reported to the VA?
251022 - ref SDS 21 JF9K While being prepared with IVs for surgery, patient
251023 - assists anesthesia find VA records on achalasia, ref SDS 21 2W4K;
251024 - Doctor Brezenski makes plans for patient care and safety so that
251025 - achalasia does not risk death during heart surgery. ref SDS 21 GX4J
251027 - ..
251028 - On 091022 cabg x4 cardiothoracic surgery San Francisco Medical Center.
251029 - ref SDS 21 PQWU
251031 - ..
251032 - On 091030 0800 at 1406 meeting with Doctor Stewart at San Francisco
251033 - Medical Center during recovery from heart surgery, proposes Heller
251034 - Myotomy surgery rather than pneumatic (balloon) dilation as more
251035 - effective and longer lasting solution to recover from swallowing and
251036 - vomitting problems caused by achalasia. ref SDS 24 KE3B
251038 - ..
251039 - On 091030 0800 at 1430 received documentation from GI Department at
251040 - San Francisco Medical Center - review shows 3 different treatments for
251041 - achalasia - pills, pneumatic dilation, Heller Myotomy surgery.
251042 - ref SDS 24 495I
251044 - ..
251045 - On 091030 0800 at 1440 meeting cardiothoracic surgery team; Doctor
251046 - Ratcliff concerned about how to maintain nutrition for the patient to
251047 - recover from heart surgery while digestion remains problematic due to
251048 - achalasia; proposes feeding tube for several months until Heller
251049 - Myotomy surgery. ref SDS 24 03GF
251051 - ..
251052 - On 091216 Heller Myotomy surgery at San Francisco VA Medical Center to
251053 - recover from achalasia. 091216 0600, ref SDS 36 KE9U
251055 - ..
251056 - On 100202 meeting with Doctor Lee - report swallowing and vomitting
251057 - problems 3 months after Heller Myotomy surgery. Doctor explains
251058 - achalasia disease breaks nerve connections from the brain that
251059 - contract the esophagus to force food and liquid from the mouth through
251060 - the esophagus; as well broken nerve connections prevent the lower
251061 - esophageal sphincter valve (LESV) to relax so that content can pass
251062 - into the stomach. Without esophageal contractions, food and liquid
251063 - can only reach the stomach with gravity, but since the LESV won't
251064 - relax the patient continues to have swallowing and vomitting problems,
251065 - despite Heller Myotomy surgery on 091216, intended to maintain
251066 - adequate opening into the stomach. ref SDS 47 485W
251068 - ..
251069 - On 100305 meeting at GI Clinic in Martinez, EGD procedure dilated LESV
251070 - from 11 to 15 mm. ref SDS 48 WR6L
251072 - ..
251073 - On 100827 meeting at GI Clinic in Martinez, EGD procedure dilated LESV
251074 - from 11 to 15 mm. ref SDS 55 JE6X
251076 - ..
251077 - On 101210 EGD procedure dilated esophageal sphincter valve (LESV)
251078 - without sedation, ref SDS 67 BE7K - dilated LESV again from 11 to 14
251079 - mm. ref SDS 67 BF6L
251081 - ..
251082 - On 101216 1021 letter commends medical team for excellent work, and
251083 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
251085 - ..
251086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using
251087 - anesthesia with Fentanyl. ref SDS 72 PQWY LESV dilated 11 - 14 mm,
251088 - and added triamcinolone steriod injections to resist contraction of
251089 - LESV so that swallowing is maintained over the next 3 month cycle.
251090 - ref SDS 72 SR4G
251092 - ..
251093 - On 110429 0830 5th EGD dilation at VA in Martinez - triamcinolone
251094 - steriod injections worked well to resist contraction of LESV so that
251095 - swallowing was maintained over the prior 3 month cycle, ref SDS 76
251096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 76 U23I, and
251097 - triamcinolone injections were continued. ref SDS 76 SS5N
251099 - ..
251100 - On 110607 1414 visited GI Department, ref SDS 78 HC5H, and Charlene
251101 - reported a computer mistakes requires scheduling next EGD dilation on
251102 - 110819 0830. ref SDS 78 N642 Requested meeting with Doctor Lee to
251103 - review pending action items. ref SDS 78 4P6J,
251105 - ..
251106 - On 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter
251107 - valve. Triamcinolone steriod injections worked well to resist
251108 - contraction of LESV so that swallowing is maintained over the prior 3
251109 - month cycle, so LESV dilated from 15 - 16.5 mm, ref SDS 81 J978, and
251110 - triamcinolone injections were continued. ref SDS 81 J985
251112 - ..
251113 - On 111115 1300 EGD dilation procedure - triamcinolone steriod injections
251114 - worked well over the prior 3 month cycle, so LESV dilated from 16.5 -
251115 - 18 mm, ref SDS 82 IR57; for some reason triamcinolone injections to
251116 - resist contraction of LESV was not performed. ref SDS 82 IS6L
251118 - ..
251119 - On 120322 1030 EGD dilation procedure - swallowing and vomitting problems
251120 - increased without triamcinolone steriod injections on prior 3 month
251121 - cycle. ref SDS 84 UI9H LESV dilated from 16.5 - 18 mm. ref SDS 84
251122 - 516N Triamcinolone injections to resist contraction of LESV was not
251123 - performed. ref SDS 84 5179
251125 - ..
251126 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA
251127 - business unit; reported patient history. ref SDS 87 RG9K Scheduled
251128 - EGD and dilation procedure for 1300; returned and performed procedure,
251129 - ref SDS 87 TB4J; dilated from 15 mm to 18 mm. ref SDS 87 XB51
251130 - Swallowing and vomitting problems increased after omitting
251131 - triamcinolone steriod injections to resist contraction of LESV after
251132 - dilation, ref SDS 87 TZ4M; therefore, injections were resumed to
251133 - complement dilation to enable and maintain effective swallowing.
251134 - ref SDS 87 R87N
251136 - ..
251137 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found
251138 - improvement recovering from acalasia, LESV contracted only slightly
251139 - from 18 mm down to 15 mm. ref SDS 95 Q333
251141 - ..
251142 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV
251143 - remained at 18 MM, ref SDS A0 CO5N, same as dialated 4 months earlier
251144 - on 130110 0900. ref SDS 95 Q333 Report CT test on 130117, shows
251145 - esophagus fully recovered from severe distortions caused by achalasia
251146 - 8 years earlier. ref SDS A0 MT6F Doctor Lee injected steriod again to
251147 - maintain swallowing. ref SDS A0 F38G Prescribed reducing Omeprazole
251148 - to 1 pill per day. ref SDS A0 R74M Scheduled next EDG dilation in 6
251149 - months, instead of 3. ref SDS A0 6P6G
251151 - ..
251152 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5
251153 - to 18 mm. ref SDS A6 CO5N Triamcinolone steriod injected again to
251154 - maintain improved swallowing. ref SDS A6 I167 Omeprazole medication
251155 - maintained 20 mg taken morning and evening for 1 month, then reduce to
251156 - 20 mg once per day. ref SDS A6 R74M Biopsies taken. ref SDS A6 3N8L
251158 - ..
251159 - On 131121 1604 ordered refill of Omeprazole to aid digestion. There
251160 - is 1 refill remaining. ref SDS A7 YS4O
251162 - ..
251163 - On 131205 1443 received order for Omeprazole prescription placed on
251164 - 131121. ref SDS A9 5N3O
251166 - ..
251167 - On 140318 1043 received letter cancelling meeting scheduled for
251168 - EGD/Dilation procedure on 140425 1000, ref SDS B2 935L; a second
251169 - letter scheduled prodedure on 140509 0900. ref SDS B2 5D7H
251171 - ..
251172 - On 140401 1659 ordered refill Omeprazole; none are remaining; need
251173 - Doctor Lee to order new prescription to increase refills. ref SDS B3
251174 - 4P5M
251176 - ..
251177 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical
251178 - center in Sacramento, Mather. ref SDS B5 K37G Pre-op preperation went
251179 - well - IV setup on first stick. ref SDS B5 EP75 Doctor ordered refills
251180 - for Omeprazole. ref SDS B5 AW5O Doctor patient partnership continues
251181 - to progress with doctor reading up on patient history to be prepared
251182 - for effective meeting. ref SDS B5 ZZ6J Doctor Lee recalled today
251183 - having made timely referral for having heart surgery, enabling patient
251184 - to recover and Half Dome 4 years later. ref SDS B5 0N6I Reported
251185 - swallowing and vomitting problems reduced past 6 months with
251186 - triamcinolone steriod injections to resist contraction of LESV.
251187 - ref SDS B5 VV6N Doctor Lee dilated LESV contracted to only 16.5 MM
251188 - over past 6 months with triamcinolone steriod injections to resist
251189 - contraction; he dilated LESV back to 18 MMy, ref SDS B5 5H5J, scheduled
251190 - next EGD dilation in 6 months since this worked well the past 6 months
251191 - with triamcinolone steriod injections. ref SDS B5 549I The doctor
251192 - explained that since there was no tearing of LESV during procedure
251193 - today, triamcinolone steriod was not injected into LESV to resist
251194 - contraction. ref SDS B5 I167 Progress notes report small tearing of
251195 - LESV during dilation procedure. ref SDS B5 P680
251197 - ..
251198 - On 140718 1017 planning for notifying VA to update current fill date
251199 - for Omeprazole. ref SDS B9 U88L Kathy visited VA in Sacramento, and
251200 - requested changing refill date for Omeprazole to 140718. ref SDS B9
251201 - OL5K VA representative called customer, and said Doctor Lee would
251202 - call back later that day to consider action on updating scheduled
251203 - refill date of Omeprazole to 140718. ref SDS B9 U76M
251205 - ..
251206 - On 140810 1839 letter to Doctor Lee requesting EGD dilation with
251207 - triamcinolone injection soonest, if cancellation occurs; but, not an
251208 - emergency, ref SDS C1 W83K, based on history rising vomitting
251209 - swallowing problems, shown in patient history case study on 120101,
251210 - beginning 140712. ref SDS 83 4E4M
251212 - ..
251213 - On 140819 0800 during meeting at VA Primary Care Clinic in Martinez,
251214 - Doctor Sandhu indicated Doctor Lee at VA Medical Center in Sacramento
251215 - will be notified about rising achalasia symptoms for consideration to
251216 - advance EGD dilation procedure. ref SDS C2 EX78
251218 - ..
251219 - On 141014 0943 Kathy visited VA Medical Center in Sacramento and met
251220 - with Lapria again, who advised that the VA responded in a letter on
251221 - 141001, to the letter on 140810, and further scheduled a meeting with
251222 - Doctor Lee on 141121 1530. ref SDS C3 QJ5N
251224 - ..
251225 - On 141103 2152 submitted agenda for meeting with Doctor Lee at VA
251226 - Sacramento Medical Center on 141107 0800, for next EGD dilation.
251227 - ref SDS C4 K37G Submit record showing normal swallowing occurs longer
251228 - with triamcinolone steriod injection to resist contraction of LESV.
251229 - ref SDS C4 3U97 Request schedule next EGD dilation in 4 months, and
251230 - if LESV does not contract, then schedule following EGD dilation in 6
251231 - months. ref SDS C4 3U66 Notified results of Half Dome hike.
251232 - ref SDS C4 3U6Y
251234 - ..
251235 - On 141107 0800 EGD dilation procedure - setting IV for conscious
251236 - sedation required 3 sticks. ref SDS C5 5W5I Meeting Doctor Lee guided
251237 - by agenda facilitated collaboration through doctor patient
251238 - partnership. ref SDS C5 VV6N Doctor explained increased difficulty
251239 - swallowing due to experiment omitting triamcinalone steriod injection
251240 - on prior procedure, ref SDS C5 4U8I, shown by LESV contracting back to
251241 - from 15 mm. ref SDS C5 T55I Progress Notes report finding ulceration
251242 - and hiatal hernia. ref SDS C5 MG6N Photographs seem to show
251243 - significantly different condition of fundoplication from a year
251244 - earlier. ref SDS C5 I74I
251246 - ..
251247 - On 150319 0800 meeting Doctor Lee in GI Clinic VA Medical Center
251248 - Sacramento report swallowing improved with triamcinalone steriod
251249 - injections on 141107 EGD dilation procedure. ref SDS D1 0M6I Doctor
251250 - Lee advised that increased orange juice consumption aids digestion,
251251 - and presents no health risks. ref SDS D1 YF5M Scheduled next EGD
251252 - dilation procedure on 150421 1300. ref SDS D1 PS4O Fundoplication
251253 - failure increases acid burn that caused ulceration with hiatal hernia
251254 - with increased recurrance achalasia. ref SDS D1 O56O Doctor Lee will
251255 - make referral to Doctor Stewart at General Surgery VA Medical Center
251256 - in San Francisco for consideration of "redo" fundaplicaiton.
251257 - ref SDS D1 JQ5J Doctor Lee completed Progress Notes for EGD dilation
251258 - on 141107. ref SDS D1 PS53 Doctor Lee will recommend Doctor Stewart
251259 - order CT test to evaluate recurrance achalasia due to failure
251260 - fundoplication. ref SDS D1 TH5M This test can include coronary CTA to
251261 - evaluate regression atherosclerosis. ref SDS D1 GB56
251263 - ..
251264 - On 150420 1752 submitted letter to Doctor Lee with agenda for meeting
251265 - the next day on 150421 1300 for EGD dilation. ref SDS D3 0M6I
251267 - ..
251268 - On 150421 Met with Doctor Lee at VA Medical Center in Sacramento
251269 - (Mather). ref SDS D4 K37G No difficulties setting IV for conscious
251270 - sedation. ref SDS D4 5W5I Reported pain level 2 right knee MCL.
251271 - ref SDS D4 LO9K Doctor Lee advised referral to San Francisco will be
251272 - filed after EDG dilation procedure (this day) to evaluate loosening
251273 - fundoplication. ref SDS D4 DZ4I Patient reported difficulty
251274 - swallowing this cycle did not occur until 4 weeks or so, because
251275 - triamcinalone steriod was injected during prior procedure on 141107,
251276 - ref SDS D4 P55L, and shown by EGD dilation LESV from 16.5 mm back to
251277 - 18 mm. ref SDS D4 HU42 Progress Notes report findings of hiatal
251278 - hernia. ref SDS D4 QD6O Impression today that ulceration has subsided
251279 - to mere errosions seems promising. ref SDS D4 PXXY
251281 - ..
251282 - On 150514 0130 letter to Doctor Lee requests file Progress Notes for
251283 - EGD Dilation today, and make referral to Doctor Stewart, to prepare
251284 - for meeting with Doctor Lee scheduled on 150521. ref SDS D6 K37G
251286 - ..
251287 - On 150521 0800 meeting with Doctor Lee at VAMC in Sacramento -
251288 - concensus uncharacteristic vomitting after recent EGD dilation
251289 - procedure on 150421, due to patient not eating slowly with small bites
251290 - and drinking liquids frequently, especially when eating meat products
251291 - that have high viscocity with esophageal tissue, and so tends to
251292 - stick, causing vomitting. ref SDS D8 WT9L
251294 - ..
251295 - On 150526 1300 meeting with Doctor Stewart Chief General Surgery VA
251296 - Medical Center San Francisco, review record indicating ulceration LESV
251297 - caused by reflux backwash into esophagus. ref SDS D9 3E4I Doctor
251298 - Stewart explained redo Dor Fundoplication required for "repairing"
251299 - original surgery, presents high risk of collateral damage. ref SDS D9
251300 - GT5G Considered increase dose Omeprazole (PPI) since ad hoc
251301 - experience occasionally taking 3 and sometimes 4 pills instead of only
251302 - 1 pill per day seemed to reduce reflux based on examination showing
251303 - ulceration of LESV declined; this would avoid need to redo Dor
251304 - Fundoplication. ref SDS D9 5Y4I
251306 - ..
251307 - On 150616 1624 received photographs on CD in word.docx file from
251308 - Phillip in ROI Department at VA MC in Sacramento (Mather) showing Dor
251309 - fundoplication in tact on 131115, beginning to unravel on 140507,
251310 - further unraveled on 141107, and unraveled on 150421. ref SDS E2 XW6M
251312 - ..
251313 - On 150623 1300 during follow up meeting, Doctor Stewart discussed
251314 - again increasing Omeprazole PPI to resolve ulceration of LESV rather
251315 - than risk difficult surgery to redo Dor fundoplication, and she
251316 - ordered prescription for H2 blocker to supplement Omeprazole PPI.
251317 - ref SDS E3 WW5K
251319 - ..
251320 - On 150624 0924 letter notified Doctor Lee of work plan to try
251321 - controlling ulceration of LESV by increasing PPI with Omeprazole
251322 - rather than chance performing high risk surgery to repair Dor
251323 - fundoplication, and that Doctor Stewart ordered H2 Blocker for Doctor
251324 - Lee to consider supplementing PPI to control acid reflux. ref SDS E4
251325 - OP91
251327 - ..
251328 - On 150624 0924 at 1344 Doctor Lee called and will order new
251329 - prescription for PPI increasing Omeprazole from 20 mg twice per day to
251330 - 40 mg twice per day. ref SDS E4 L861
251332 - ..
251333 - On 150925 0336 request switch back to Omeprazole 20 mg twice per day
251334 - in order to reduce severe side effects of dehydration from frequent
251335 - urination causing scaling, peeling, bleeding feet; lower dose
251336 - Omeprazole enables hiking to raise HDL required to regress
251337 - atherosclerosis plaques, thereby lowering risks of CVD and CAD.
251338 - ref SDS E6 5G8T As a result, Pharmacy VA Medical Center San Francisco
251339 - entered new prescription for (PPI) Omeprazole 20 mg. ref SDS E6 FK66
251341 - ..
251342 - On 150925 0336 VA scheduled next meeting for EGD dilation on 151204
251343 - 0800. ref SDS E6 SR6L
251345 - ..
251346 - On 151002 1820 Doctor Lee returned call; will order Omeprazole 20 mg
251347 - prescription sufficient until next EGD Dilation procedure on 151204,
251348 - and complimenting prescription entered on 150925 for only 1 month.
251349 - ref SDS E7 NV5I
251351 - ..
251352 - On 151012 1151 VA Internet Pharmacy lists updated Omeprazole 20 mg
251353 - prescription. ref SDS D5 0C5H
251355 - ..
251356 - On 151204 0800 met with Doctor Lee at VA Medical Center in Sacramento
251357 - (Mather); initial administration went well. ref SDS F4 GD4H
251358 - Preparation for the procedure was professional; no difficulties
251359 - setting IV for conscious sedation today. ref SDS F4 544G The doctor
251360 - reported not receiving letter with agenda for the meeting today,
251361 - submitted on 151201. ref SDS F4 VV6N Patient difficulty swallowing
251362 - occurred after 5 months, because triamcinalone steriod injected prior
251363 - procedure on 150421. Swallowing difficulty/vomiting increased over
251364 - the next 3 months indicates dilate LESV 18 mm and doing EGD dilation
251365 - in 6 rather than 8 months. ref SDS F4 P55L Asked about Baking Soda to
251366 - clear throat in order to avoid vomitting, and prevent ulceration LESV
251367 - alternative to Omeprazole in order to avoid side effects causing
251368 - dehydration. ref SDS F4 G53K Performing EGD dilation procedure went
251369 - smoothly, with no difficulties. ref SDS F4 7V6I Post procedure Doctor
251370 - Lee reported LESV contracted to 10 mm, the worst results in patient
251371 - history, indicating 2 month delay performing procedure this cycle was
251372 - harmful. ref SDS F4 5H5J
251373 -
251374 -
251375 -
251376 -
251377 -
251378 -
251380 - ..
2514 -
2515 -
2516 - Progress
251701 - ..
251702 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
251703 - GI Department VA Sacramento Medical Center Administration EGD Dilation
251704 -
251705 - Follow up ref SDS F4 NU8L, ref SDS D4 NU8L.
251706 -
251707 - Meeting today implements planning for next EGD dilation in 4 months,
251708 - reported in meeting with Doctor Lee on 151210 0800. ref SDS F6 UR5K
251709 - The doctor's Progress Notes say 4 - 6 months. 151210 0800, ref SDS F6
251710 - KI79 Patient history indicates recurrence of LESV contraction to 10
251711 - mm requires to 3 month treatment cycles. ref SDS F6 QR8H On 160104
251712 - 1349 letter to Jessica, Doctor Lee's Administrative Assistant,
251713 - requested meeting for EGD dilation on 160304, or as soon as possible
251714 - after 160304, and to schedule meeting with Doctor Lee to review
251715 - treatment plan a week after EGD Dilation. ref SDS G0 K37G
251717 - ..
251718 - On 160104 1349 at 1532 received letter from Jessica saying Dr Lee's
251719 - notes states 4-6mos from 12/4/15. You were placed on the "reminder
251720 - system" for 4 mos. We do not schedule more than 3mos out. Due in
251721 - April 2016. 160104 1349, ref SDS G0 LW7O On 160106 2131 letter to
251722 - Doctor Lee confirms planning for EGD dilations on 3 month intervals,
251723 - and schedule next EGD dilation OA 160304 0800. ref SDS G2 T257
251725 - ..
251726 - On 160116 Doctor Stewart scheduled to review viability surgical
251727 - solution achalasia Dor fundoplication issues on 160705, anticipates 2
251728 - EGD dilation procedures on 3 month intervals to restore swallowing
251729 - from current LES V 10 mm toward prior favorable LESV 18 mm. (See
251730 - Progress Notes for Surgery Clinic on 160119. ref SDS G3 6R92
251732 - ..
251733 - On 160126 0004 letter notifies Doctor Lee at GI Clinic in VA Medical
251734 - Center at Sacramento Mather Air Force Base, that Doctor Stewart in
251735 - Surgery Clinic requested 2 EGD dilations on 3 month intervals to
251736 - support follow up evaluation for surgical solution to achalasia (Dor
251737 - fundoplication) issue, which requires next EGD dilation OA 160304.
251738 - ref SDS G4 NU8L
251740 - ..
251741 - On 160208 1031 called VAMCSAC talked to Jessica; she scheduled next
251742 - EGD dilation on 160315 0900, ref SDS G5 VB9P; and scheduled next
251743 - consult on 160405 0930. ref SDS G5 VB96
251745 - ..
251746 - Agenda for meeting today was not submitted to Doctor Lee.
251748 - ..
251749 - Applied pre-proc requirements for NPO after midnight, from letter on
251750 - 101015 1547. ref SDS 59 4J9L Last food was at......
251752 - ..
251753 - Stayed in Concord last night. This morning, Kathy drove us to VA
251754 - Medical Center at Mather AFB in Sacrmento.
251756 - ..
251757 - Checked into GI Department at the customer counter.
251758 -
251759 - 800-382-8387
251760 -
251761 - 916 843 7000
251763 - ..
251764 - Kathy cell phone for designated driver...
251768 - ..
251769 - Kathy signed the discharge form affirming she will be designated
251770 - driver, and responsible to facilitate no driving for 24 hours.
251772 - ..
251773 - Nurse at customer counter asked questions on patient history to verify
251774 - ready for procedure, e.g., no allergies, and NPO after midnight to
251775 - avoid conflicts with anesthesia; no health problems, e.g., no
251776 - diabetes, alcohol, cigarettes.
251778 - ..
251779 - Waited in lobby for 5 minutes. Then Jessica called to prepare for
251780 - procedure.
251781 -
251783 - ..
2518 -
2519 -
2520 - 0907
2521 -
252101 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
252102 -
252103 - Follow up ref SDS F4 EP75, ref SDS D4 EP75.
252104 -
252105 - Jessica took vitals today, prior to procedure in a small office just
252106 - off the lobby, and not in the treatment center, reported on 120925
252107 - 0900. ref SDS 87 PT5P
252109 - ..
252110 - Vital included...
252111 -
252112 - Weight.................. 188 (fully dressed, shoes, cell phone)
252113 - BP...................... 140 81
252114 - HR (pulse).............. 64
252115 - Temp.................... 97.0
252117 - ..
252118 - Jessica led the way into the OR preparation room, and assisted with
252119 - dressing down and laying on a gurney.
252121 - ..
252122 - Grace performed prepartion work. Configured on gurney and connected
252123 - equipment to monitor vitals during the procedure.
252125 - ..
252126 - Grace set catheter IV for sedation. Required only 1 stick.
252128 - ..
252129 - Case study on sticks required to set catheter is reported on 110429
252130 - 1230. ref SDS 76 UO3G
252132 - ..
252133 - Grace went through patient identification and medical profile filling
252134 - out forms on the computer.
252136 - ..
252137 - She asked about pain? Reported level 6 to right knee, continuing
252138 - injury reported on 160229, in case study on 140101 0600. ref SDS B0
252139 - QVXP
252141 - ..
252142 - Waited about 20 minutes.
252143 -
252144 -
252145 -
252147 - ..
2522 -
2523 -
2524 - 0940
2525 -
252501 - Consent Signed EGD Dilation and Meeting Review Pending Issues
252502 - Consultation Pending Issues and Sign Consent for EGD Dilation
252503 -
252504 - Follow up ref SDS F4 RG9K, ref SDS D4 RG9K.
252505 -
252506 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation
252507 - procedure today.
252509 - ..
252510 - Noted that signature is entered on completely black screen, required
252511 - without reading online documents.
252512 -
252513 -
252514 -
252515 -
252516 -
252517 -
252519 - ..
252520 - Swallowing Vomitting Difficulties Resolved with Triamcinolone Injections
252521 - Triamcinolone Injection Prevent LESV Contraction Avoid Swallowing Vomitting Problems
252522 -
252523 - Follow up ref SDS F4 VV6N, ref SDS D4 VV6N.
252524 -
252525 - Doctor Lee plans to use Triamcinolone steroid injection during the
252526 - procedure today, based on favorable results, and planning during the
252527 - meeting on 150319 0800, ref SDS D1 6P9M, and as applied during prior
252528 - EGD dilation on 151204 0800. ref SDS F4 LC98
252530 - ..
252531 - Doctor Lee asked about swallowing problems?
252533 - ..
252534 - Advised that swallowing and vomiting are presented in letter to the
252535 - doctor on 160106, saying "Swallowing has started to be difficult, but
252536 - still manageable with minimal vomitting. ref SDS G2 T29R Another
252537 - letter 20 days later reported "Main problem to solve is food backing
252538 - up due to recurrent distended esophagus," shown on 160126 0004.
252539 - ref SDS G4 TT8H
252541 - ..
252542 - Doctor Lee said he had forgotten reports of worsening swallowing, and
252543 - requests for EGD dilation procedure. While we talked, the doctor
252544 - tried to access the letter on the computer in the procedure
252545 - preparation room, and located next to the bed. The VA computer was
252546 - slow this morning, so he abandoned this effort to review the record.
252548 - ..
252549 - As previously on 151204, ref SDS F4 5Q4I, past 6 weeks beginning
252550 - approximately on 160203, saliva tends to build up in the esophagus,
252551 - and vomitting has increased by orders of magnitude, shown in case
252552 - study patient history on 140101 0600. ref SDS B0 9X9H
252554 - ..
252555 - Baking soda has been helpful to relieve pressure from reflux in order
252556 - to prevent ulceration of LESV, see for example the record on 160220,
252557 - shown in case study on 140101 0600. ref SDS B0 8H9K Reliance on
252558 - baking soda enables reducing use of Omeprazole, which then prevents
252559 - dehydration. This enables feet injuries to recover so that hiking can
252560 - be increased to a level that raises HDL > 60, which then regresses
252561 - atherosclerosis, reported in research on 131125 0005. ref SDS A8 Z49G
252562 - and ref SDS A8 VE3G and ref SDS A8 HG90
252564 - ..
252565 - Doctor Lee explained prior analysis that reliance on Baking Soda is
252566 - not recommended because only short time relief occurs, and high
252567 - concentration of sodium increases atherosclerosis, presented during
252568 - the meeting on 151204 0800. ref SDS F4 EY9K
252570 - ..
252571 - Research on taking Baking Soda to prevent acid reflux is reported on
252572 - 151204 0800. ref SDS F4 H76M
252573 -
252574 - [...below on 160315 0900 Doctor Lee's Progress Notes report
252575 - patient obtaining interim relief from reflux using sodium
252576 - bicarbonate. ref SDS 0 3H5L
252578 - ..
252579 - [...below on 160315 0900 Doctor Lee's Progress Notes report
252580 - there is no longer any associated erosive esophagitis and
252581 - there is no evidence of mass effect. This implies better
252582 - acid suppression compared to the previous examination of
252583 - December 2015. The patient's symptoms of breakthrough for
252584 - which he has been using sodium bicarbonate does indicate an
252585 - area for improvement. ref SDS 0 PXXY
252587 - ..
252588 - Estimated LESV will engage today at < 13mm, based on recent swallowing
252589 - problems.
252590 -
252591 - [...below on 160315 0900 at 1250 after the procedure Doctor
252592 - Lee reported LESV contracted this cycle to 9.5 mm from 15,
252593 - and so he could only dilate today back to 15 mm.
252594 - ref SDS 0 7Q6L
252596 - ..
252597 - Doctor Lee will report in Progress Notes right knee pain level 6, per
252598 - report to Grace, above. ref SDS 0 6P9I
252600 - ..
252601 - Signed consent for the procedure, which is not visible - there is
252602 - merely a black screen to sign.
252603 -
252604 -
252605 -
252606 -
252608 - ..
2527 -
2528 -
2529 - 1052
2530 -
253001 - OR EGD Dilation with Application Lidocaine
253002 - EGD Dilation Procedure in OR Application Lidocaine
253003 -
253004 - Follow up ref SDS F4 7V6I, ref SDS D4 7V6I.
253005 -
253006 - Grace wheeled the gurney into the OR for the procedure.
253008 - ..
253009 - Everything went smoothly, as always.
253011 - ..
253012 - Nurse in OR applied conscious sedation using the catheter set by Grace
253013 - in Preparation, per above. ref SDS F4 544G
253014 -
253015 - [...below on 160315 0900 Progress Notes report intravenous
253016 - medication applied for conscious sedation. ref SDS 0 P341
253018 - ..
253019 - The team then did the EDG/dilation procedure.
253020 -
253021 -
253022 -
253024 - ..
253025 - Dilated 15 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee
253026 - Meeting Doctor Lee Present Results EGD Dilation Procedure 15 MM
253027 - Results EGD Dilation Procedure Meeting Doctor Lee Present 15 MM
253028 -
253029 - Follow up ref SDS F4 5H5J, ref SDS D4 5H5J.
2531 -
2532 -
2533 - 1210
253401 - ..
253402 - After recovery from the procedure, met with Doctor Lee in a small
253403 - office next to Prep and Recovery area.
253405 - ..
253406 - Doctor Lee advised that EGD examination today, found LESV contracted
253407 - 9.5 mm from 15 mm down to 9.5 mm again, showing no improvement since
253408 - prior dilation 4 months ago on 151204 0800. ref SDS F4 HU42 LESV
253409 - contraction to 9.5 mm is worst condition in patient history, shown in
253410 - case study below. ref SDS 0 LD8O Continual worsening of LESV
253411 - contraction to 9.5 mm aligns with severe swallowing problems shown by
253412 - increased vomiting, reported prior to the procedure, per above.
253413 - ref SDS 0 P55L This indicates continual effects of 2 month delay
253414 - performing EGD on 151204. ref SDS F4 6P6G
253415 -
253416 - [...below on 160315 0900 Findings report LESV contracted
253417 - to 9.5 mm. ref SDS 0 7Q6L
253419 - ..
253420 - Doctor Lee advised that triamcinolone steriod was injected again
253421 - today, in order to restore and maintain improved swallowing for the
253422 - next 6 months, as it has the past 4 years, since 120925...
253423 -
253424 - L E S V D I A L A T I O N
253425 - Months from - to
253426 - Interval Date mm mm
253427 - 4 160315 9.5 15.....triamcinolone..3.0mL... ref SDS 0 HU42
253428 - 8 151204 10 15.....triamcinolone..5.0mL... ref SDS F4 HU42
253429 - 6 150421 16.5 18.....triamcinolone..3.0mL... ref SDS D4 HU42
253430 - 6 141107 15 18.....triamcinolone..4.0mL... ref SDS C5 I167
253431 - 6 140509 16.5 18............................ ref SDS B5 P680
253432 - 7 131115 16.5 18.....triamcinolone..2.0mL... ref SDS A6 RZ45
253433 - 3 130416 18 18.....triamcinolone..2.0mL... ref SDS A0 Y850
253434 - 4 130110 15 18.....triamcinolone..3.0mL... ref SDS 95 Q333
253435 - 6 120925 15 18.....triamcinolone..4.0mL... ref SDS 87 XB51
253436 - 4 120322 16.5 18............................ ref SDS 84 516N
253437 - 3 111115 16.5 18............................ ref SDS 82 IR57
253438 - 4 110819 15 16.5...triamcinolone..2.5mL... ref SDS 81 J978
253439 - 3 110429 13 16.5...triamcinolone..3.5mL... ref SDS 76 U23I
253440 - 3 110218 11 14.....triamcinolone..2.0mL... ref SDS 72 AA5O
253441 - 4 101210 11 14............................ ref SDS 67 H347
253442 - 5 100827 11 15............................ ref SDS 55 JE6X
253443 - 3 100305 11 15............................ ref SDS 48 WR6L
253444 - 091216 Heller Myotomy Fundoplication...... ref SDS 36 KE9U
253445 -
253447 - ..
253448 - Background on triamcinolone injection is further reviewed in the
253449 - record for the meeting at the VA on 140509 0900. ref SDS B5 R26H
253450 -
253451 -
253453 - ..
253454 - Ulceration LESV Improved
253455 -
253456 - Follow up ref SDS F4 RZ3G.
253457 -
253458 - Doctor Lee reported finding improved esophagitis today, which seems to
253459 - indicate prior worsening ulceration, reported on 151204 0800,
253460 - ref SDS F4 RZ3G, has been resolved with the current reduced dose of
253461 - Omeprazole and combined with adding Famotidine and Mylanta (Mintox),
253462 - prescribed during prior meeting on 151204 0800. ref SDS F4 Y69F
253464 - ..
253465 - [...below on 160315 0900 Progress Notes say "...there is no
253466 - longer any associated erosive esophagitis. ref SDS 0 PXXY
253468 - ..
253469 - Doctor Lee cautioned again against taking Baking Soda to relieve
253470 - reflux, discussed previously on 151204 0800. ref SDS F4 G53K
253471 -
253472 -
253474 - ..
253475 - Next Meeting 3 Months Decreased from 4 Months Due to Severe Symptoms
253476 -
253477 - Follow up ref SDS F4 4U5F.
253478 -
253479 - Doctor Lee wants the next EGD dilation in 3 months, in order to begin
253480 - the process of increasing LESV back to 18 mm baseline, as done
253481 - previously, when LESV contracted to 11 mm, beginning on 101210 0930.
253482 - ref SDS 67 NP6R
253484 - ..
253485 - Asked Doctor Lee to discuss this with Jessica before ending the
253486 - meeting in order to avoid prior delays relying on the computer
253487 - scheduling system.
253489 - ..
253490 - After post-procedure meeting we visited Jessica. Doctor Lee asked
253491 - Jessica to schedule the next meeting in 3 months. Jessica entered
253492 - the next EGD dilation procedure to be performed on 160617.
253493 -
253494 -
253495 -
253496 -
253497 -
253498 -
253499 -
2535 -
SUBJECTS
Medical Chart Progress Notes VA EGD Procedure Stricture Lower Esopha
5503 -
550401 - ..
550402 - Release of Information ROI CD Contents Received on 151224
550403 -
550404 - Follow up ref SDS F4 CY7I, ref SDS D4 CY7I.
550406 - ..
550407 - Decided to request records on CD from ROI for this medical encounter
550408 - due to continual difficulties downloading medical records from VA
550409 - website at...
550410 -
550411 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
550412 -
550419 - ..
550420 - On 151219 sent letter to ROI VAMC Sacramento, with attached VA Form
550421 - 10-5345A requesting medical records for this medical encounter.
550422 - ref SDS F9 2E96
550424 - ..
550425 - On 151224 received following medical records on CD and stored in...
550426 -
550427 - F:\05\00003\SM\CC\AGMJ\20160315-090000\mhv_WELCH_20160808_0656.txt
550429 - ..
550430 - This file includes numerous reports flowing from EGD Dilation
550431 - procedure on 151204, and follow up meeting a week later on 151210;
550432 - there is no particular order for the records in this file...
550433 -
550434 - 1. LEGACY VISTA BLOOD BANK REPORT
550436 - ..
550437 - The purpose of this entry is unclear.
550438 -
550439 - 2. SURGICAL PATHOLOGY
550441 - ..
550442 - This is biopsy results for EGD dilation procedure on 151204.
550443 -
550444 - 3. PROGRESS NOTES EGD 60111................. ref SDS F4 9N5G
550446 - ..
550447 - This is the main explanation prepared by Doctor Lee for EGD Dilation
550448 - procedure today.
550449 -
550450 - 4. PRE-PROCEDURE NOTE 60302................. ref SDS F4 ZN3M
550452 - ..
550453 - This lists administration and preparation activities for EGD Dilation
550454 - procedure today.
550455 -
550456 - 5. GASTROENTEROLOGY ATTENDING F/U NOTE 60127..... 151210 0800, ref SDS F6 AV8K
550458 - ..
550459 - This is Doctor Lee's Progress Notes for the meeting on 151210, where
550460 - results were reviewed of EGD Dilation procedure on 151204, and work
550461 - plan was developed for home care until the next EGD Dilation in 4
550462 - months, on 160304.
550463 -
550464 - 6. GI DISCHARGE INSTRUCTIONS................. ref SDS F4 U76O
550466 - ..
550467 - This is the VA's letter to itself claiming to represent verbal and
550468 - written instructions discussed with the patient following recovery
550469 - from sedation for EGD Dilation procedure on 151204.
550470 -
550472 - ..
550473 - Progress Notes EGD Dilation Today
550474 -
550475 - Follow up ref SDS F4 9N5G, ref SDS D4 CY7I.
550476 -
550477 - 1. LOCAL TITLE: EGD 60111
550478 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
550479 - DATE OF NOTE: MAR 15, 2016@09:00 ENTRY DATE: MAR 15, 2016@13:02:22
550480 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
550481 - URGENCY: STATUS: COMPLETED
550482 -
550483 - *** EGD 60111 Has ADDENDA ***
550485 - ..
550486 - EGD 1573438:
550487 - TTS balloon distal esophageal stricture 10-15mm
550488 - injected with triamcinolone
550489 - biopsied.
550490 - no obvious malignancy.
550491 - repeat 3 months
550492 -
550493 - /es/ Randall E. Lee, MD
550494 - Staff Physician, Gastroenterology
550495 - Signed: 03/15/2016 13:03
550496 -
550497 - 03/15/2016 ADDENDUM STATUS: COMPLETED
550501 - ..
550502 - 2. NAME OF PROCEDURE:
550503 -
550504 - 1. Esophagogastroduodenoscopy.
550505 - 2. Endoscopic biopsy.
550506 - 3. TTS balloon dilation with esophageal stricture.
550507 - 4. Endoscopic triamcinolone injection.
550509 - ..
550510 - 3. ATTENDING PHYSICIAN:
550511 - Randall E. Lee, M.D.
550513 - ..
550514 - 4. INDICATIONS:
550518 - ..
550519 - 71-year-old man with an underlying history of achalasia in 2009
550520 - after undergoing coronary artery bypass and graft. He
550521 - underwent laparoscopic myotomy and fundoplication at the San
550522 - Francisco VA. He subsequently developed acid reflux
550523 - complicated by recurrent distal esophageal stricture. His last
550524 - EGD and dilation was December 2015 at which time his distal
550525 - esophagus was noted again to be strictured and the diagnostic
550526 - gastroscope could not be advanced through the area. He
550527 - underwent dilation from 10-15 mm and received triamcinolone
550528 - acetate injected into the area. Since then, because he has
550529 - been having side effects associated with omeprazole, this was
550530 - reduced to 20 mg every other day. Famotidine had been
550531 - prescribed through the San Francisco VA and this was continued
550532 - at a dose of 20 mg at bedtime. He is also taking 30 mL of
550533 - liquid antacid at bedtime.
550535 - ..
550536 - In the interim, he has noted an increase in his dysphagia grade to
550537 - where solid food is predictably becoming stuck. He also has been
550538 - having some breakthrough symptoms during the daytime for which he uses
550539 - sodium bicarbonate.
550541 - ..
550542 - L E S V D I A L A T I O N
550543 - Months from - to
550544 - Interval Date mm mm
550545 - 4 160315 9.5 15.....triamcinolone..3.0mL... ref SDS 0 7Q6L
550546 - 8 151204 10 15.....triamcinolone..5.0mL... ref SDS F4 HU42
550547 - 6 150421 16.5 18.....triamcinolone..3.0mL... ref SDS D4 HU42
550548 - 6 141107 15 18.....triamcinolone..4.0mL... ref SDS C5 I167
550549 - 6 140509 16.5 18............................ ref SDS B5 P680
550550 - 7 131115 16.5 18.....triamcinolone..2.0mL... ref SDS A6 RZ45
550551 - 3 130416 18 18.....triamcinolone..2.0mL... ref SDS A0 Y850
550552 - 4 130110 15 18.....triamcinolone..3.0mL... ref SDS 95 Q333
550553 - 6 120925 15 18.....triamcinolone..4.0mL... ref SDS 87 XB51
550554 - 4 120322 16.5 18............................ ref SDS 84 516N
550555 - 3 111115 16.5 18............................ ref SDS 82 IR57
550556 - 4 110819 15 16.5...triamcinolone..2.5mL... ref SDS 81 J978
550557 - 3 110429 13 16.5...triamcinolone..3.5mL... ref SDS 76 U23I
550558 - 3 110218 11 14.....triamcinolone..2.0mL... ref SDS 72 AA5O
550559 - 4 101210 11 14............................ ref SDS 67 H347
550560 - 5 100827 11 15............................ ref SDS 55 JE6X
550561 - 3 100305 11 15............................ ref SDS 48 WR6L
550562 - 091216 Heller Myotomy Fundoplication...... ref SDS 36 KE9U
550563 -
550565 - ..
550566 - 5. CONSENT:
550567 -
550568 - The risks, benefits, and alternatives to this procedure
550569 - including but not limited to the risks of bleeding and bowel
550570 - perforation were explained to the patient. The patient
550571 - understood and provided a written informed consent.
550573 - ..
550574 - Patient signed blank screen, at request of doctor, per above.
550575 - ref SDS 0 8R5F
550577 - ..
550578 - Progress Notes EGD Dilation procedure on 160315 continues...
550579 -
550580 - 6. INTRAVENOUS MEDICATION:
550581 -
550582 - 1. Diphenhydramine 25 mg.
550583 - 2. Fentanyl 250 mcg.
550584 - 3. Midazolam 5 mg.
550585 -
550587 - ..
550588 - 7. PROCEDURE:
550589 -
550590 - 1. In the Sacramento VA GI Endoscopy Unit, the patient was placed in the
550591 - left lateral decubitus position.
550592 -
550593 - 2. Oxygen at 2 liters per minute by nasal cannula was
550594 - administered. Continuous oximetric and hemodynamic
550595 - monitoring was initiated.
550597 - ..
550598 - 3. Intravenous sedation was administered in divided doses.
550600 - ..
550601 - 4. After a bite block was placed in the patient's mouth, an
550602 - Olympus GIF-HQ190 videogastroscope was advanced under
550603 - direct vision to the esophagus.
550605 - ..
550606 - 5. An esophageal stricture immediately at the GE junction at a
550607 - distance of about 36 cm was encountered. This was passed
550608 - with a diagnostic endoscope using mild pressure.
550610 - ..
550611 - 6. The endoscope was then advanced into the third portion of
550612 - the duodenum.
550614 - ..
550615 - 7. Retroflexed views of the incisura, fundus, and cardia were
550616 - performed.
550618 - ..
550619 - 8. Biopsies were taken from the GE junction within the
550620 - strictured area labeled specimen A. This was located at 36
550621 - cm.
550623 - ..
550624 - 9. A TTS balloon was then advanced across the stricture
550625 - and inflated sequentially from 10 to 11 to 12 mm. This
550626 - balloon was deflated and then replaced with a second
550627 - balloon, which was then sequentially inflated from 12 to
550628 - 13.5 to 15 mm.
550629 -
550630 - [...below on 160315 0900 Findings report LESV contracted
550631 - to 9.5 mm. ref SDS 0 7Q6L
550633 - ..
550634 - 10. Circumference of the strictured area was then injected with
550635 - submucosal injections of triamcinolone acetate at a
550636 - concentration of 40 mg/mL. Total dose was about 3 mL. The
550637 - stomach was decompressed and the gastroscope removed.
550639 - ..
550640 - Case study shows favorable history injecting triamcinolone...
550641 -
550642 - L E S V D I A L A T I O N
550643 - Months from - to
550644 - Interval Date mm mm
550645 - 4 160315 9.5 15.....triamcinolone..3.0mL... ref SDS 0 7Q6L
550646 - 8 151204 10 15.....triamcinolone..5.0mL... ref SDS F4 HU42
550647 - 6 150421 16.5 18.....triamcinolone..3.0mL... ref SDS D4 HU42
550648 - 6 141107 15 18.....triamcinolone..4.0mL... ref SDS C5 I167
550649 - 6 140509 16.5 18............................ ref SDS B5 P680
550650 - 7 131115 16.5 18.....triamcinolone..2.0mL... ref SDS A6 RZ45
550651 - 3 130416 18 18.....triamcinolone..2.0mL... ref SDS A0 Y850
550652 - 4 130110 15 18.....triamcinolone..3.0mL... ref SDS 95 Q333
550653 - 6 120925 15 18.....triamcinolone..4.0mL... ref SDS 87 XB51
550654 - 4 120322 16.5 18............................ ref SDS 84 516N
550655 - 3 111115 16.5 18............................ ref SDS 82 IR57
550656 - 4 110819 15 16.5...triamcinolone..2.5mL... ref SDS 81 J978
550657 - 3 110429 13 16.5...triamcinolone..3.5mL... ref SDS 76 U23I
550658 - 3 110218 11 14.....triamcinolone..2.0mL... ref SDS 72 AA5O
550659 - 4 101210 11 14............................ ref SDS 67 H347
550660 - 5 100827 11 15............................ ref SDS 55 JE6X
550661 - 3 100305 11 15............................ ref SDS 48 WR6L
550662 - 091216 Heller Myotomy Fundoplication...... ref SDS 36 KE9U
550664 - ..
550665 - Progress Notes EGD Dilation procedure on 160315 continues...
550666 -
550667 - 8. COMPLICATIONS:
550668 -
550669 - None immediate.
550671 - ..
550672 - Ulceration LESV and Hiatal Hernia Findings Fundoplication Failed
550673 -
550674 - Follow up ref SDS F4 P396, ref SDS D4 P396.
550675 -
550676 - 9. FINDINGS:
550677 -
550678 - 1. Proximal mid esophagus dilated and without evidence of
550679 - peristalsis. The esophageal mucosa appears smooth and
550680 - without erosions, ulcerations or mass effect.
550682 - ..
550683 - 2. Distal esophageal stricture again noted at the GE junction.
550684 - Initial diameter was approximately 9.5 mm. This was
550685 - dilated to 15 mm.
550687 - ..
550688 - Findings reporting LESV dilated from 9.5 mm to 15 mm, aligns with
550689 - report during post procedure meeting Doctor Lee, per above.
550690 - ref SDS 0 545L
550692 - ..
550693 - Dilating LESV from 9.5 mm to 15 mm relates to explanation in Procedure
550694 - section above; report of dilating from 10 mm may reflect that forcing
550695 - the gastroscope through LESV dilated from 9.5 to 10 mm. ref SDS 0 HU42
550697 - ..
550698 - Progress Notes EGD Dilation procedure on 160315 continues...
550699 -
550700 - 3. Gastric fundus surgically altered consistent with prior
550701 - history of fundoplication. This appears to have relaxed.
550703 - ..
550704 - 4. Hiatal hernia is clearly visible.
550705 - 5. Normal pylorus.
550706 - 6. Normal duodenum to D3.
550707 -
550709 - ..
550710 - 10. IMPRESSION:
550711 -
550712 - 1. Gastroesophageal reflux stricture, recurrent. There is no
550713 - longer any associated erosive esophagitis and there is no
550714 - evidence of mass effect. This implies better acid
550715 - suppression compared to the previous examination of
550716 - December 2015. The patient's symptoms of breakthrough for
550717 - which he has been using sodium bicarbonate does indicate an
550718 - area for improvement.
550720 - ..
550721 - 2. Evidence of recurrent acid reflux stricture suggests
550722 - continued consideration for surgical repair.
550724 - ..
550725 - Reporting resolution of esophagitis shows substantial recovery from
550726 - prior worsening condition found during EGD dilation 4 months ago on
550727 - 151204 0800. ref SDS F4 PXXY
550729 - ..
550730 - This part of Progress Notes seems conflicting. If "There is no longer
550731 - any associated erosive esophagitis and there is no evidence of mass
550732 - effect," as a result of better acid suppression, then why is
550733 - consideration of surgical repair needed? This may relate to fixing
550734 - Dor fundoplication that has failed. But, since Dor fundoplication
550735 - prevents ulceration of LESV, if there is no ulceration, why consider
550736 - surgical repair?
550738 - ..
550739 - May be a good explanation, just confusing.
550741 - ..
550742 - Progress Notes EGD Dilation procedure on 160315 continues...
550743 -
550744 - 11. RECOMMENDATIONS:
550745 -
550746 - 1. Increase famotidine to 20 mg twice daily once in the morning and
550747 - once at bedtime.
550749 - ..
550750 - 2. Await the pathology results.
550752 - ..
550753 - 3. Repeat EGD and dilation in approximately 3 months.
550755 - ..
550756 - After post-procedure meeting, Doctor Lee met with Jessica and
550757 - coordinated scheduling next procedure on 160617, per above.
550758 - ref SDS 0 4U5F
550760 - ..
550761 - Progress Notes EGD Dilation procedure on 160315 continues...
550762 -
550763 - 12. DISPOSITION:
550764 -
550765 - 1. The patient was observed in the Recovery Room then discharged to
550766 - home with a companion.
550768 - ..
550769 - 2. I reviewed the endoscopic findings with the patient prior to
550770 - discharge.
550772 - ..
550773 - 3. The patient requests that I note that he is having
550774 - approximately 6/10 right knee pain, which he attributes to
550775 - a recent long distance hike. As he is planning a hike to
550776 - Half Dome in Yosemite this summer, he is requesting
550777 - referral to Physical Therapy / Physical Medicine &
550778 - Rehabilitation for advice about a knee brace or leg
550779 - strengthening exercises. He prefers SFVA for this.
550780 -
550782 - ..
550783 - 13. TIME START: 1120 hours.
550785 - ..
550786 - 14. TIME END: 1144 hours.
550787 -
550788 - D: 03/15/2016
550789 - T: 03/17/2016
550790 - Job number: 1573438
550791 - LRM/CMTS
550792 - $end:
550793 -
550795 - ..
550796 - The doctor seems to have appended a section of the biopsy report to
550797 - the end of Progress Notes in order to enter a relevant comment.
550798 - ref SDS F4 9P4N
550800 - ..
550801 - Progress Notes EGD Dilation procedure on 151204 continues...
550802 -
550803 - Microscopic exam/diagnosis: (Date Spec taken: Mar 15, 2016)
550804 - GE JUNCTION AT 36 CM (BIOPSY):
550805 - - SQUAMOCOLUMNAR MUCOSA WITH ULCER AND NECROINFLAMMATORY DEBRIS
550806 - - PAS STAIN NEGATIVE FOR FUNGUS
550807 - - NEGATIVE FOR INTESTINAL METAPLASIA
550808 -
550809 - /es/ Randall E. Lee, MD
550810 - Staff Physician, Gastroenterology
550811 - Signed: 04/07/2016 09:31
550812 -
550813 -
550814 -
550815 -
550816 -
550817 -
550818 -
550819 -
550820 -