CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10
2503 -
2503 - ..
2504 - Summary/Objective
2505 -
250501 - Follow up ref SDS G8 0000. ref SDS G6 0000.
250502 -
250503 - Diffuculty swallowing this cycle began about 2 weeks ago. ref SDS 0
250504 - P55L Signed blank consent for the procedure today, on assurance from
250505 - Doctor Lee that stroke symptoms following prior EGD on 160617, would
250506 - not recur. ref SDS 0 BH9G EGD dilation procedure went smoothly, with
250507 - no reports of difficulties. ref SDS 0 7V6I Post procedure Doctor Lee
250508 - reported LESV contracted back to 9.5 mm, the wors in patient history,
250509 - indicating 2 month delay to 8 months performing procedure in December
250510 - causing continual injury. ref SDS 0 5H5J Ulceration got worse this
250511 - past cycle, which prevented the doctor from dilating LESV needed for
250512 - better swallowing. ref SDS 0 RZ3G Doctor Lee prescribed Pantoprazole
250513 - 40 mg twice a day to replace taking Omeprazole and Famotidine.
250514 - ref SDS 0 Q05K Next meeting in 3 weeks. ref SDS 0 4U5F
250515 -
250516 -
250517 -
250518 -
250519 -
250521 - ..
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 A8 5N3O
251166 - ..
251167 - On 140318 1043 received letter cancelling meeting scheduled for
251168 - EGD/Dilation procedure on 140425 1000, ref SDS B1 935L; a second
251169 - letter scheduled prodedure on 140509 0900. ref SDS B1 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 B2
251174 - 4P5M
251176 - ..
251177 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical
251178 - center in Sacramento, Mather. ref SDS B4 K37G Pre-op preperation went
251179 - well - IV setup on first stick. ref SDS B4 EP75 Doctor ordered refills
251180 - for Omeprazole. ref SDS B4 AW5O Doctor patient partnership continues
251181 - to progress with doctor reading up on patient history to be prepared
251182 - for effective meeting. ref SDS B4 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 B4 0N6I Reported
251185 - swallowing and vomitting problems reduced past 6 months with
251186 - triamcinolone steriod injections to resist contraction of LESV.
251187 - ref SDS B4 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 B4 5H5J, scheduled
251190 - next EGD dilation in 6 months since this worked well the past 6 months
251191 - with triamcinolone steriod injections. ref SDS B4 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 B4 I167 Progress notes report small tearing of
251195 - LESV during dilation procedure. ref SDS B4 P680
251197 - ..
251198 - On 140718 1017 planning for notifying VA to update current fill date
251199 - for Omeprazole. ref SDS B8 U88L Kathy visited VA in Sacramento, and
251200 - requested changing refill date for Omeprazole to 140718. ref SDS B8
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 B8 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 C0 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 C1 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 C2 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 C3 K37G Submit record showing normal swallowing occurs longer
251228 - with triamcinolone steriod injection to resist contraction of LESV.
251229 - ref SDS C3 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 C3 3U66 Notified results of Half Dome hike.
251232 - ref SDS C3 3U6Y
251234 - ..
251235 - On 141107 0800 EGD dilation procedure - setting IV for conscious
251236 - sedation required 3 sticks. ref SDS C4 5W5I Meeting Doctor Lee guided
251237 - by agenda facilitated collaboration through doctor patient
251238 - partnership. ref SDS C4 VV6N Doctor explained increased difficulty
251239 - swallowing due to experiment omitting triamcinalone steriod injection
251240 - on prior procedure, ref SDS C4 4U8I, shown by LESV contracting back to
251241 - from 15 mm. ref SDS C4 T55I Progress Notes report finding ulceration
251242 - and hiatal hernia. ref SDS C4 MG6N Photographs seem to show
251243 - significantly different condition of fundoplication from a year
251244 - earlier. ref SDS C4 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 D0 0M6I Doctor
251250 - Lee advised that increased orange juice consumption aids digestion,
251251 - and presents no health risks. ref SDS D0 YF5M Scheduled next EGD
251252 - dilation procedure on 150421 1300. ref SDS D0 PS4O Fundoplication
251253 - failure increases acid burn that caused ulceration with hiatal hernia
251254 - with increased recurrance achalasia. ref SDS D0 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 D0 JQ5J Doctor Lee completed Progress Notes for EGD dilation
251258 - on 141107. ref SDS D0 PS53 Doctor Lee will recommend Doctor Stewart
251259 - order CT test to evaluate recurrance achalasia due to failure
251260 - fundoplication. ref SDS D0 TH5M This test can include coronary CTA to
251261 - evaluate regression atherosclerosis. ref SDS D0 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 D2 0M6I
251267 - ..
251268 - On 150421 Met with Doctor Lee at VA Medical Center in Sacramento
251269 - (Mather). ref SDS D3 K37G No difficulties setting IV for conscious
251270 - sedation. ref SDS D3 5W5I Reported pain level 2 right knee MCL.
251271 - ref SDS D3 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 D3 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 D3 P55L, and shown by EGD dilation LESV from 16.5 mm back to
251277 - 18 mm. ref SDS D3 HU42 Progress Notes report findings of hiatal
251278 - hernia. ref SDS D3 QD6O Impression today that ulceration has subsided
251279 - to mere errosions seems promising. ref SDS D3 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 D5 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 D7 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 D8 3E4I Doctor
251298 - Stewart explained redo Dor Fundoplication required for "repairing"
251299 - original surgery, presents high risk of collateral damage. ref SDS D8
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 D8 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 E1 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 E2 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 E3
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 E3 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 E5 5G8T As a result, Pharmacy VA Medical Center San Francisco
251339 - entered new prescription for (PPI) Omeprazole 20 mg. ref SDS E5 FK66
251341 - ..
251342 - On 150925 0336 VA scheduled next meeting for EGD dilation on 151204
251343 - 0800. ref SDS E5 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 E6 NV5I
251351 - ..
251352 - On 151012 1151 VA Internet Pharmacy lists updated Omeprazole 20 mg
251353 - prescription. ref SDS D4 0C5H
251355 - ..
251356 - On 151204 0800 met with Doctor Lee at VA Medical Center in Sacramento
251357 - (Mather); initial administration went well. ref SDS F3 GD4H
251358 - Preparation for the procedure was professional; no difficulties
251359 - setting IV for conscious sedation today. ref SDS F3 544G The doctor
251360 - reported not receiving letter with agenda for the meeting today,
251361 - submitted on 151201. ref SDS F3 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 F3 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 F3 G53K Performing EGD dilation procedure went
251369 - smoothly, with no difficulties. ref SDS F3 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 F3 5H5J
251374 - ..
251375 - On 151210 meeting Doctor Lee after EGD on 151204, changed prescription
251376 - of Omeprazole (PPI) to 20 mg every other day to eliminate or reduce
251377 - dehydration from frequent urination, and in order for feet to recover
251378 - from peeling, cracking, bleeding so that hiking can be performed at
251379 - level of 300 miles per month required to raise HDL > 60, required to
251380 - regress athersclerosis. ref SDS F6 J56O Doctor prescribed adding
251381 - Famotidine an H2 blocker taken once a day to compliment Omeprazole.
251382 - ref SDS F6 YL3M
251384 - ..
251385 - On 160325 0900 Diffuculty swallowing this cycle began about 1 month
251386 - after prior EGD dilation on 151204. ref SDS G6 P55L Reported using
251387 - baking soda to relieve reflux that prevents ulceration LESV; this
251388 - reduced Omeprazole in order to avoid dehydration. ref SDS G6 Z84H
251389 - Progress Notes report there is no longer any erosive esophagitis and
251390 - there is no evidence of mass effect, which implies better acid
251391 - suppression compared to previous examination December 2015.
251392 - ref SDS G6 PXXY EGD dilation procedure went smoothly, with no reports
251393 - of difficulties. ref SDS G6 7V6I Post procedure Doctor Lee reported
251394 - LESV contracted to 9.5 mm, the smallest in patient history, indicating
251395 - 2 month delay to 8 months performing procedure in December causing
251396 - continual injury. ref SDS G6 5H5J
251397 -
251398 -
251399 -
251400 -
251401 -
251403 - ..
2515 -
2516 -
2517 - Progress
251801 - ..
251802 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
251803 - GI Department VA Sacramento Medical Center Administration EGD Dilation
251804 -
251805 - Follow up ref SDS G8 NU8L, ref SDS G6 NU8L.
251806 -
251807 - Meeting today implements planning for EGD dilation today, scheduled by
251808 - Doctor Lee during telecon on 160812 1626. ref SDS H6 G64I This is 3
251809 - weeks in advance of original schedule on 160909, ordered by Doctor Lee
251810 - following the prior procedure on 160617 0800. ref SDS G8 4U5F
251812 - ..
251813 - Applied pre-proc requirements for NPO after midnight, from letter on
251814 - 101015 1547. ref SDS 59 4J9L Last food was at......
251816 - ..
251817 - Stayed in Concord last night. This morning, Kathy drove us to VA
251818 - Medical Center at Mather AFB in Sacrmento.
251820 - ..
251821 - Checked into GI Department at the customer counter..
251822 -
251823 - 800-382-8387
251824 -
251825 - 916 843 7000
251827 - ..
251828 - Kathy cell phone for designated driver...
251832 - ..
251833 - Kathy signed the discharge form affirming she will be designated
251834 - driver, and responsible to facilitate no driving for 24 hours.
251836 - ..
251837 - Nurse at customer counter asked questions on patient history to verify
251838 - ready for procedure, e.g., no allergies, and NPO after midnight to
251839 - avoid conflicts with anesthesia; no health problems, e.g., no
251840 - diabetes, alcohol, cigarettes.
251842 - ..
251843 - Waited in lobby for 10 minutes. Then Jessica called to prepare for
251844 - procedure.
251845 -
251847 - ..
2519 -
2520 -
2521 - 0817
2522 -
252201 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
252202 -
252203 - Follow up ref SDS G8 EP75, ref SDS G6 EP75.
252204 -
252205 - Tommy took vitals today, prior to procedure in a small office just off
252206 - the lobby, and not in the treatment center, reported on 120925 0900.
252207 - ref SDS 87 PT5P
252209 - ..
252210 - Vital included...
252211 -
252212 - Weight.................. 179.2 (fully dressed, shoes, cell phone)
252213 - BP...................... 132 78
252214 - HR (pulse).............. 61
252215 - Temp.................... 98.1
252217 - ..
252218 - Returned to patient waiting area.
252220 - ..
252221 - In about 5 minutes, Grace called patient into OR preparation room, and
252222 - assisted with dressing down and laying on a gurney.
252224 - ..
252225 - Grace configured on gurney and connected equipment to monitor vitals
252226 - during the procedure.
252228 - ..
252229 - Grace set catheter IV for sedation. Required only 1 stick, so better
252230 - today than last time on 141107 0800. ref SDS C4 544G
252232 - ..
252233 - Case study on sticks required to set catheter is reported on 110429
252234 - 1230. ref SDS 76 UO3G
252236 - ..
252237 - Grace went through patient identification and medical profile filling
252238 - out forms on the computer.
252240 - ..
252241 - She asked about pain? Reported level 0.
252243 - ..
252244 - Waited about 30 minutes.
252245 -
252246 -
252247 -
252249 - ..
2523 -
2524 -
2525 - 0847
2526 -
252601 - Consent Signed EGD Dilation and Meeting Review Pending Issues
252602 - Consultation Pending Issues and Sign Consent for EGD Dilation
252603 -
252604 - Follow up ref SDS G8 RG9K, ref SDS G6 RG9K.
252605 -
252606 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation
252607 - procedure today.
252609 - ..
252610 - Noted that signature is entered on completely black screen, required
252611 - without reading online documents.
252613 - ..
252614 - Agenda Meeting Doctor Lee...
252615 -
252616 - 1. Schedule follow up meeting next week...
252618 - ..
252619 - Doctor Lee said he wants to keep the meeting previously scheduled on
252620 - 160909, so he can expand LESV to 18 mm.
252621 -
252623 - ..
252624 - 2. Interim report on Peer Review.
252625 -
252626 - What has been done?
252628 - ..
252629 - Doctor Lee was unaware of what has been done. He said the Peer
252630 - Review process is independent and so he is not involved in order to
252631 - ensure objective review.
252632 -
252634 - ..
252635 - What remains to be done?
252637 - ..
252638 - Doctor Lee said he does not know the status of the review provess.
252639 -
252641 - ..
252642 - Estimated completion date?
252644 - ..
252645 - Doctor Lee said he has not been briefed on the completion date.
252646 -
252648 - ..
252649 - Disposition?
252651 - ..
252652 - Doctor Lee seemed to say the Peer Review report will be discussed
252653 - during a meeting among the GI Clinic doctors.
252654 -
252656 - ..
252657 - 3. LESV contracted to 9.5 mm, reported on 160617 0800. ref SDS G8
252658 - 6P6G
252660 - ..
252661 - Hopefully, it will only be contracted to 11 or 12 mm since expanding
252662 - to 15 mm on 160617.
252663 -
252665 - ..
252666 - 4. Could we increase baking soda, given patient level of exercise
252667 - hiking that extricates excess salt, and thereby further reduce
252668 - ulceration?
252670 - ..
252671 - Doctor Lee does not support increasing baking soda, because results
252672 - are short term, and increased sodium intake conflicts with patient
252673 - profile of CAD, shown by CABG x4 surgery on 091022 0700. ref SDS 21
252674 - PQWU
252676 - ..
252677 - We reviewed the record using Baking Soda reported in EGD Progress
252678 - Notes showing ulceration/esophagitis completely resolved on 160315
252679 - 0900. ref SDS G6 PXXY
252681 - ..
252682 - On 151019, CCTA showed patient completely clear of atherosclerosis.
252683 - ref SDS F0 SU62 More recently, on 160618, MRI study found no evidence
252684 - of atherosclerosis in blood vessels of the brain. ref SDS H0 J738 The
252685 - test 2 weeks ago on 160805, confirmed this finding. ref SDS H3 HX5H
252686 - Since there is no evidence of atherosclerosis, the patient can absorb
252687 - some excessive salt in order to resolve severe ulceration.
252688 -
252690 - ..
252691 - 5. Surgical repair resolve achalasia cited in Progress Notes on
252692 - 160617 0800. ref SDS G8 TU9H
252693 -
252694 -
252695 - 1. Could Doctor Lee ask around at VAMC Sacramento for 2nd
252696 - opinion on surgical repair, to supplement Doctor Stewart's
252697 - considerations at VAMCSF?
252699 - ..
252700 - Doctor Lee did not comment on this initiative.
252701 -
252703 - ..
252704 - 2. Another idea would be to re-slice/cut LESV with the aim of
252705 - extending the time for closure from 2 - 3 months, back to 6
252706 - months.
252707 -
252708 -
252710 - ..
252711 - 3. Stent advantages and risks?
252713 - ..
252714 - Doctor Lee cited recent articles reporting poor results for stents.
252715 - He did not present any specific sources on this.
252716 -
252717 - [On 160823 1430 during meeting at VAMCSF Doctor Stewart
252718 - said several times that stent does not seem like a good
252719 - solution in this case. Mentioned Doctor Bhat as best GI
252720 - physician for performing this procedure at VAMCSF.
252721 - ref SDS H9 0T7O
252722 -
252724 - ..
252725 - 6. Medication - update prescription to 30 ml twice per day, so it
252726 - will last in the VA computer, planned in telecon on 160714
252727 - 0814. ref SDS 6 HV4N
252729 - ..
252730 - Doctor Lee placed this order before the procedure began.
252731 -
252733 - ..
252734 - 7. Medication - consider alternate PPI switch from Omeprazole that
252735 - has adverse side effects of severe dehydration due to freequent
252736 - urination, to another medication, discussed on 160714 0814.
252737 - ref SDS 6 HV4H
252739 - ..
252740 - Debbie in GI Clinic at VAMCSF mentioned Pantorazole
252741 - reported in the record on 160722 1335. ref SDS 9 3K32
252743 - ..
252744 - After the procedure, Doctor Lee ordered change from Omeprazole to
252745 - Panotrazole that will increase recovery from ulceration.
252747 - ..
252748 - After the procedure, and while in recovery, a nurse called Kathy into
252749 - the patient area. Gave Kathy VA card, and she went to the Pharmacy
252750 - and got the medication.
252751 -
252752 -
252754 - ..
252755 - Swallowing Vomitting Difficulties Resolved with Triamcinolone Injections
252756 - Triamcinolone Injection Prevent LESV Contraction Avoid Swallowing Vomitting Problems
252757 -
252758 - Follow up ref SDS G8 VV6N, ref SDS G6 VV6N.
252759 -
252760 - Doctor Lee did not discuss plans to use Triamcinolone steroid
252761 - injection during the procedure today. Background on prior use is
252762 - reported on 160617 0800. ref SDS G8 VV6N
252764 - ..
252765 - Case study on 160617, indicates Progress Notes show that 2 mL has
252766 - maintained LESV dilation for 6 month treatment cycles. 160617 0800.
252767 - ref SDS G8 LD8O This calculates to .33 mL/month. Since 161204,
252768 - patient has received 13 mL Triamcinolone over 8 months, which
252769 - calculates to 1.625 mL per month, a 500% increase.
252771 - ..
252772 - On 160617, patient received 5.0 mL, which added to 3 mL on 160315,
252773 - makes 8 mL in 3 months, which calculates to 2.57 mL/month, and so
252774 - equals 800% increase over patient history. Research indicates 1.5 mL
252775 - for common adult dose, but does not present frequency of dosage.
252776 - Agressive treatment of 2 - 3 mL in this case for 6 months, would
252777 - indicate 5.0 mL injected on 160617, would be effective for 12 months
252778 - until 170617.
252780 - ..
252781 - Accordingly, though not expressly discussed during the meeting today,
252782 - Triamcinolone was likely not injected for the procedure today, since
252783 - prior treatment should still be effective for several more months.
252784 -
252785 - [On 160907 1420 letter to medical team presents expectation
252786 - that Triamcinolone was not injected for procedure on
252787 - 160817, and would not be injected for follow on procedure
252788 - in 2 days on 160909, because Triamcinolone injection of 5
252789 - mL on 160617 would have continuing effects for several more
252790 - months. ref SDS I1 BI63
252792 - ..
252793 - [On 160909 0800 corrected erroneous expectation - Doctor
252794 - Lee advised during a meeting to perform another EGD
252795 - procedure that about 5.0 mL was injected into LESV during
252796 - prior procedure on 160816. ref SDS I2 L44J
252797 -
252799 - ..
252800 - LESV DILATE Triamcin Diphenhy Fenta Bena Midaz Lido
252801 - Months from - to olone Versed dramine nyl dryl olam caine
252802 - Interval Date mm mm mL mg mg mg mg mg mL
252803 - 2 160816 9.5 9.5....5.0.....6..............250.....50...............5...... ref SDS 0 HU42
252804 - *1 3 160617 9.5 15......5.0.....6..............250.....50...............5...... ref SDS G8 HU42
252805 - *2 4 160315 9.5 15......3.0............25......250.............5........5...... ref SDS G6 HU42
252806 - 8 151204 10 15......5.0............25......200.............5........5...... ref SDS F3 HU42
252807 - 6 150421 16.5 18......3.0............50......250.............4........5...... ref SDS D3 HU42
252808 - 6 141107 15 18......4.0............50......150.............5........5...... ref SDS C4 E54M
252809 - 6 140509 16.5 18.....................50......200.............5........5...... ref SDS B4 P680
252810 - 7 131115 16.5 18......2.0............50......200.............4........5...... ref SDS A6 RZ45
252811 - 3 130416 18 18......2.0.....5..............250.....50...............5...... ref SDS A0 Y850
252812 - 4 130110 15 18......3.0............50......100.............4........5...... ref SDS 95 Q333
252813 - *3 6 120925 15 18......4.0............50......200.............5........5...... ref SDS 87 XB51
252814 - 4 120322 16.5 18.....................50......150.............4........5...... ref SDS 84 516N
252815 - 3 111115 16.5 18.....................50......200.............4........5...... ref SDS 82 IR57
252816 - 4 110819 15 16.5....2.5............50......200.............5........5...... ref SDS 81 J978
252817 - 3 110429 13 16.5....3.5.....5..............200.....50...............5...... ref SDS 76 U23I
252818 - 3 110218 11 14......2.0............50......150.............4........5...... ref SDS 72 AA5O
252819 - 4 101210 11 14......................................................5...... ref SDS 67 H347
252820 - 5 100827 11 15..............5..............250.....50...............5...... ref SDS 55 JE6X
252821 - 3 100305 11 15..............5..............250.....50...............5...... ref SDS 48 WR6L
252822 - 091216 Heller Myotomy Fundoplication....................................... ref SDS 36 KE9U
252823 -
252824 -
252825 -
252827 - ..
252828 - Doctor Lee was familiar with rising swallowing problems shown by
252829 - increased vomiting the past several weeks, reported in the letter to
252830 - the medical team on 160801 1428. ref SDS H2 WX53 The problem was
252831 - discussed most recently, when Doctor Lee called last week on 160812
252832 - 1626, ref SDS H6 G64I, following up a letter to the medical team on
252833 - 160810 0453. ref SDS H4 2958 Doctor Lee also discussed rising
252834 - achalasia symptoms with Doctor Massa last week on 160611, where Doctor
252835 - Massa explained again patient suffering increased swallowing problems,
252836 - 160811 1546, ref SDS H5 HR5O, leading to Doctor Lee's decision to
252837 - order the EGD Dilation procedure today for exigent care.
252839 - ..
252840 - Estimated LESV will engage today at < 13mm, based on recent swallowing
252841 - problems (e.eg., see beginning on 160101, in case study on 140101
252842 - 0600. ref SDS A9 UA6K).
252843 -
252844 - [...below on 160816 0800 at 1120 after the procedure Doctor
252845 - Lee reported LESV contracted this cycle back to 9.5 mm from
252846 - 15 mm dilated 2 months ago on 160167, ref SDS 0 5H5J; he
252847 - also reported increased ulceration LESV prevented any
252848 - dilation, signaling worst condition in patient history.
252849 - ref SDS 0 RZ3G
252851 - ..
252852 - Asked Doctor Lee again, if he is sure today, that stroke symptoms of
252853 - left side motor control and vision impairment following EGD procedure
252854 - on 160167, ref SDS G9 5F6F, will not recur, repeating question
252855 - presented last week on 160812 1626? ref SDS H6 RS4F
252857 - ..
252858 - Doctor Lee said there is no reason to believe prior problems will
252859 - recur today.
252861 - ..
252862 - Signed consent for the procedure, which is not visible - there is
252863 - merely a black screen to sign.
252864 -
252865 -
252866 -
252867 -
252869 - ..
2529 -
2530 -
2531 - 0922
2532 -
253201 - OR EGD Dilation with Application Lidocaine
253202 - EGD Dilation Procedure in OR Application Lidocaine
253203 -
253204 - Follow up ref SDS G8 7V6I, ref SDS G6 7V6I.
253205 -
253206 - Grace wheeled the gurney into the OR for the procedure.
253208 - ..
253209 - Everything went smoothly, as always.
253211 - ..
253212 - Grace applied conscious sedation using the catheter set in
253213 - Preparation, per above. ref SDS 0 544G
253215 - ..
253216 - The team then did the EDG/dilation procedure.
253217 -
253218 -
253219 -
253221 - ..
253222 - Meeting Doctor Lee Present Results EGD Dilation Procedure 10 MM
253223 - Results EGD Dilation Procedure Meeting Doctor Lee Present 10 MM
253224 -
253225 - Follow up ref SDS G8 5H5J, ref SDS G6 5H5J.
2533 -
2534 -
2535 - 1124
253601 - ..
253602 - An hour or so after the procedure, met with Doctor Lee in the recovery
253603 - room.
253605 - ..
253606 - Doctor Lee advised that EGD examination today, found LESV contracted
253607 - back to 9.5 mm again. Very disappointing there was again no
253608 - improvement since prior procedure 2 months earlier on 160617 0800,
253609 - ref SDS G8 6P6G, indicating continuing difficulties resulting from 2
253610 - month delay extending prior 6 month procedures to 8 months on 151204
253611 - 0800. ref SDS F3 6P6G
253613 - ..
253614 - Doctor Lee did not say that triamcinolone steriod was injected again
253615 - today, in order to restore and maintain swallowing. This may reflect
253616 - patient history receiving 5.0 mL injection of triamcinolone on 160167,
253617 - ref SDS G8 V48Y, and that it continues to be effective for several
253618 - more months, reviewed above. ref SDS 0 FJ5I
253619 -
253620 - [On 160816 1532 letter notifies medical team that LESV
253621 - contracted back to 9.5 mm, worst condition in patient
253622 - history, and that ulceration on LESV was so severe that
253623 - dilation could not be performed to improve swallowing.
253624 - ref SDS H7 NK98
253626 - ..
253627 - [On 160823 0920 Doctor Massa called and asked if Doctor Lee
253628 - injected LESV with Triamcinolone; advised that Progress
253629 - Notes not available to determine Triamcinolone was or was
253630 - not injected on 160816. ref SDS H8 NG47
253632 - ..
253633 - [On 160907 1420 letter notifies medical team that
253634 - Triamcinolone likely not administered for EGD on 160817,
253635 - because dose over prior 3 month period accumulated to
253636 - significantly more than commonly given in this case.
253637 - ref SDS H0 BI60
253638 -
253639 -
253640 -
253641 -
253642 -
253644 - ..
253645 - Ulceration LESV Increased Prevented Dilating LESV Above 10 MM
253646 - Dilated 10 MM Rather than Healthy LESV 20 MM Due to Increased Ulceration
253647 -
253648 - Follow up ref SDS G8 RZ3G, ref SDS G6 RZ3G.
253649 -
253650 - Doctor Lee reported significantly increased ulceration LESV from prior
253651 - examination on 160617 0800. ref SDS G8 RZ3G He was unable to dilate
253652 - LESV above 10 mm, because this would have damaged the component.
253654 - ..
253655 - He estimates dilation to 10 mm because that is the size of the Olympia
253656 - Gastroscope instrument used to perform EGD procedure by pushing it
253657 - through LESV which necessarily expands the opening to that diameter.
253659 - ..
253660 - Discharge documents show no dilation.
253661 -
253662 - [On 160816 1532 letter notifies medical team that LESV
253663 - contracted back to 9.5 mm, worst condition in patient
253664 - history, and that ulceration on LESV was so severe that
253665 - dilation could not be performed to improve swallowing.
253666 - ref SDS H7 NK98
253668 - ..
253669 - This aligns with eliminating Baking Soda, reducing Omeprazole taking
253670 - 20 mg every other day, to prevent debilitating side effects, discussed
253671 - with Doctor Lee on 160315 0900, ref SDS G6 RZ3G; and, further
253672 - increasing Famotidine to 20 mg twice per day, prescribed during prior
253673 - meeting with Doctor Lee on 160315 0900. ref SDS G6 ZQ4H
253674 -
253676 - ..
253677 - Pantoprazole Prescirbed Replace Omeprazole and Famotidine
253678 -
253679 - Doctor Lee prescribed eliminating Famotidine and Omeprazole, and
253680 - adding Pantoprazole 40 mg twice per day for resolving increased
253681 - esophagitis.
253682 -
253683 -
253685 - ..
253686 - Next Meeting 3 Weeks to Recover Severe Symptoms
253687 -
253688 - Follow up ref SDS G8 4U5F, ref SDS G6 4U5F.
253689 -
253690 - Doctor Lee left the priviously scheduled EGD Dilation on 160909, to
253691 - prevent severe contraction of LESV to 9.5 mm, that occurred over the
253692 - past 2 months causing severe vomiting, and leading to no dilation, and
253693 - in order to restore standard of care dilating to 18 mm, per above.
253694 - ref SDS 0 6P6G
253695 -
253696 -
253697 -
253698 -
253699 -
253700 -
253701 -
253702 -
253703 -
253704 -
2538 -
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 G8 CY7I, ref SDS G6 CY7I.
550406 - ..
550407 - Request records on CD from ROI for this medical encounter due to
550408 - continual difficulties downloading medical records from VA website
550409 - at...
550410 -
550411 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
550412 -
550419 - ..
550420 - On September 7, 2016, checked for Progress Notes for EGD on 160617,
550421 - and found they have not yet been posted for patient access.
550422 -
550423 -
550424 -
550425 -
550906 -
550907 -
550908 -
550909 -
550910 -
550911 -
550912 -
550913 -
550914 -
550915 -
550916 -
550917 -
550918 -