CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10
2503 -
2503 - ..
2504 - Summary/Objective
2505 -
250501 - Follow up ref SDS H8 0000. ref SDS G8 0000.
250502 -
250503 - Miraculously, there has been no diffuculty swallowing this cycle
250504 - despite not having dilated LESV 3 weeks ago on 160816. ref SDS 0 VV6N
250505 - Signed blank consent for the procedure today, on assurance from Doctor
250506 - Lee that stroke symptoms following prior EGD on 160617, would not
250507 - recur. ref SDS H8 BH9G EGD dilation procedure went smoothly, with no
250508 - reports of difficulties. ref SDS H8 7V6I Post procedure Doctor Lee
250509 - reported LESV contracted back to 9.5 mm, the wors in patient history,
250510 - indicating 2 month delay to 8 months performing procedure in December
250511 - causing continual injury. ref SDS H8 5H5J Ulceration got worse this
250512 - past cycle, which prevented the doctor from dilating LESV needed for
250513 - better swallowing. ref SDS H8 RZ3G Doctor Lee prescribed Pantoprazole
250514 - 40 mg twice a day to replace taking Omeprazole and Famotidine.
250515 - ref SDS H8 Q05K Next meeting in 3 weeks. ref SDS H8 4U5F
250516 -
250517 -
250518 -
250519 -
250520 -
250522 - ..
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 steroid 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 - steroid 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 steroid 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 steroid 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 steroid 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 steroid 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 steroid 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 steroid 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 steroid 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 steroid 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 steroid injections. ref SDS B4 549I The doctor
251192 - explained that since there was no tearing of LESV during procedure
251193 - today, triamcinolone steroid 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 steroid 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 steroid 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 steroid
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 steroid 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 steroid 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 H8 NU8L, ref SDS G8 NU8L.
251806 -
251807 - Meeting today implements planning for EGD dilation scheduled by Doctor
251808 - Lee during meeting following prior EGD procedure on 160816 0800,
251809 - ref SDS H8 4U5F, by leaving previous schedule unchanged originally set
251810 - on 160617 0800. ref SDS G8 4U5F This is just a 3 week interval. The
251811 - shortest previous interval was 3 months, seen in case study on 160617
251812 - 0800. ref SDS G8 LD8O
251814 - ..
251815 - Frequency and time interval between procedures correlates with side
251816 - effects from medications, including Triamcinolone.
251818 - ..
251819 - Applied pre-proc requirements for NPO after midnight, from letter on
251820 - 101015 1547. ref SDS 59 4J9L Last food was at......
251822 - ..
251823 - Stayed in Concord last night. This morning, Kathy drove us to VA
251824 - Medical Center at Mather AFB in Sacrmento.
251826 - ..
251827 - Checked into GI Department at the customer counter..
251828 -
251829 - 800-382-8387
251830 -
251831 - 916 843 7000
251833 - ..
251834 - Kathy cell phone for designated driver...
251838 - ..
251839 - Kathy signed the discharge form affirming she will be designated
251840 - driver, and responsible to facilitate no driving for 24 hours.
251842 - ..
251843 - Nurse at customer counter asked questions on patient history to verify
251844 - ready for procedure, e.g., no allergies, and NPO after midnight to
251845 - avoid conflicts with anesthesia; no health problems, e.g., no
251846 - diabetes, alcohol, cigarettes.
251848 - ..
251849 - Waited in lobby for 10 minutes. Then Jessica called to prepare for
251850 - procedure.
251851 -
251853 - ..
2519 -
2520 -
2521 - 0817
2522 -
252201 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
252202 -
252203 - Follow up ref SDS H8 EP75, ref SDS G8 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.................. 189.1 (fully dressed, shoes, cell phone)
252213 - BP...................... 151 74
252214 - HR (pulse).............. 61
252215 - Temp.................... 97.3
252217 - ..
252218 - Research on 160617, found that Triamcinolone steroid injections can
252219 - increase weight and blood pressure. 160617 0800, ref SDS G8 PG6I
252221 - ..
252222 - Returned to patient waiting area.
252224 - ..
252225 - In about 3 minutes, Tommy called patient into OR preparation room.
252227 - ..
252228 - Grace assisted with dressing down and laying on a gurney.
252230 - ..
252231 - Grace configured on gurney and connected equipment to monitor vitals
252232 - during the procedure.
252234 - ..
252235 - Connie set catheter IV for sedation. Required only 1 stick, so better
252236 - today than last time on 141107 0800. ref SDS C4 544G
252238 - ..
252239 - Case study on sticks required to set catheter is reported on 110429
252240 - 1230. ref SDS 76 UO3G
252242 - ..
252243 - Denise went through patient identification and medical profile filling
252244 - out forms on the computer.
252246 - ..
252247 - She asked about pain? Reported level 0.
252249 - ..
252250 - Waited about 30 minutes.
252251 -
252252 -
252253 -
252255 - ..
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 H8 RG9K, ref SDS G8 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. Progress Notes for 160816, need printed copy - not available
252617 - online.
252619 - ..
252620 - Doctor Lee said he has not signed Progess Notes for meeting on
252621 - 160816, because the tanscription has many errors that take time to
252622 - correct before he can sign them.
252624 - ..
252625 - This is similar to using OCR software to convert printed text into an
252626 - editable computer file. There are usually so many errors that it
252627 - takes less time to just type the entire document.
252628 -
252629 -
252631 - ..
252632 - 2. Schedule follow up meeting to review findings for EGD dilation
252633 - today, and plan adjustments for the next cycle.
252635 - ..
252636 - After the procedure, Doctor Lee submitted notice that meeting to
252637 - review pending issues, and from the meeting today is scheduled on
252638 -
252639 - 160921 1130
252641 - ..
252642 - He will submit Progress Notes for meeting today, and for prior
252643 - meeting on 160816.
252644 -
252645 -
252647 - ..
252648 - 3. Interim report on Peer Review on cause of stroke symptoms
252649 - following EGD on 160617?
252651 - ..
252652 - What has been done?
252654 - ..
252655 - Doctor Lee said the Peer Review process will be discussed at Doctors
252656 - Conference in the next week or so, then will be finalized in a
252657 - published report on cause of stroke symptoms following EGD on 160617
252658 - 1637. ref SDS G9 5F6F
252660 - ..
252661 - Doctor Lee appreciated getting a call from Doctor Massa several weeks
252662 - ago, cited in Doctor Lee's Progress Notes the next day on 160812 1626,
252663 - ref SDS H7 AQ9N, concurring with Doctor Massa's assessment that stroke
252664 - symptoms after EGD on 160617, ref SDS G9 5F6F, likely arose from
252665 - something that occurred during EGD procedure, as set out in Doctor
252666 - Massa's letter on 160811 1546. ref SDS H6 3K9J
252667 -
252669 - ..
252670 - 4. LESV contracted to 9.5 mm, reported on 160617 0800. ref SDS G8
252671 - 6P6G
252673 - ..
252674 - Progress Notes seem to say LESV contracted to 12mm on 160617. This
252675 - appears conflicting with post procedure reporting, Discharge document,
252676 - and correlations with patient history. ref SDS G8 HU42
252678 - ..
252679 - Doctor Lee said he will check the record on this matter.
252680 -
252681 -
252683 - ..
252684 - 5. Baking soda was used this cycle to compliment Pantoprazole and
252685 - Mylanta, in fact Mylanta was abandoned becuase of erratic
252686 - digestion effects.
252688 - ..
252689 - On 160315, Progress Notes report ulceration resolved, while
252690 - taking Baking Soda to compliment Omperazole. ref SDS G6 PXXY
252692 - ..
252693 - Doctor Lee today, supports using baking soda despite concerns reported
252694 - on 160816 0800. ref SDS H8 XY5M
252696 - ..
252697 - On 151019, CCTA showed patient completely clear of atherosclerosis.
252698 - ref SDS F0 SU62 More recently, on 160618, MRI study found no evidence
252699 - of atherosclerosis in blood vessels of the brain. ref SDS H0 J738 The
252700 - test 2 weeks ago on 160805, confirmed this finding. ref SDS H4 HX5H
252702 - ..
252703 - Since radiology evidence shows patient no longer suffers
252704 - atherosclerosis because hiking achieved HDL 73, the patient can absorb
252705 - some excessive salt associated with Baking Soda treatment in order to
252706 - resolve severe ulceration, similar to tolerating aggressive dose of
252707 - Triamcinolone in order to maintain LESV dilation, shown in case study
252708 - on 160617 0800. ref SDS G8 LD8O
252710 - ..
252711 - Doctor Lee prescribed taking Baking Soda between meals and taking
252712 - Pantoprazole. This aligns with current practice.
252713 -
252715 - ..
252716 - 6. Surgical repair resolve achalasia cited in Progress Notes on
252717 - 160617 0800. ref SDS G8 TU9H
252718 -
252719 -
252720 - 1. Could Doctor Lee ask around at VAMC Sacramento for 2nd
252721 - opinion on surgical repair, to supplement Doctor Stewart's
252722 - considerations at VAMCSF?
252724 - ..
252725 - During meeting at VAMCSF, Doctor Stewart seemed to feel this might be
252726 - viable in the event swallowing cannot be improved with dilation. She
252727 - ordered a sonogram of caroited artery scheduled on 160920, reported
252728 - on, ref SDS I1 4K7F
252730 - ..
252731 - This was not actually discussed today.
252733 - ..
252734 - Will review during next meeting with Doctor Lee in 2 weeks on 160921
252735 - 1130, to follow up procedure today, and as discussed during prior EGD
252736 - on 160816 0800. ref SDS H8 O97M
252737 -
252739 - ..
252740 - 2. Stent advantages and risks?
252742 - ..
252743 - On 160816, Doctor Lee cited recent articles reporting poor results for
252744 - stents. ref SDS H8 DE9G
252746 - ..
252747 - Need source for these articles.
252749 - ..
252750 - On 160823 1430 during meeting at VAMCSF Doctor Stewart said several
252751 - times that stent does not seem like a good solution in this case.
252752 - Mentioned Doctor Bhat as best GI physician for performing this
252753 - procedure at VAMCSF. ref SDS I1 0T7O
252755 - ..
252756 - Does Doctor Lee know Doctor Bhat personally through medical
252757 - conferences or by reputation?
252759 - ..
252760 - Actually, today, did not discuss this matter.
252761 -
252763 - ..
252764 - 7. Medication - explain paused Mylanta to avoid adverse side
252765 - effects.
252766 -
252768 - ..
252769 - 8. Medication - consider adjust PPI dose from Pantoprazole 40 mg
252770 - twice daily, to once per day for relief from adverse side
252771 - effects of severe dehydration due to freequent urination.
252773 - ..
252774 - This has increased by 200% the past week.
252776 - ..
252777 - Doctor Lee prescribed continuing current prescription Pantoprazole 40
252778 - mg twice per day, until follow up meeting on 160921 1130, and then
252779 - review adjustments at that time.
252780 -
252781 -
252783 - ..
252784 - Swallowing Vomitting Difficulties Resolved with Triamcinolone Injections
252785 - Triamcinolone Injection Prevent LESV Contraction Avoid Swallowing Vomitting Problems
252786 -
252787 - Follow up ref SDS H8 VV6N, ref SDS G8 VV6N.
252788 -
252789 - Doctor Lee seemed to say he had not read the copy he received of the
252790 - letter submitted to the medical team 2 days ago, on 160907 1420,
252791 - ref SDS I2 R66J, and which cited case study injecting Triamcinolone
252792 - steroid, including procedure on 160617 0800, after which stroke
252793 - symptoms occurred. ref SDS G8 V48Y
252795 - ..
252796 - Reviewed possibility that overdose of Triamcinolone can cause loss of
252797 - vision that occurred following EGD on 160617 1637, ref SDS G9 5F6F,
252798 - referencing research earlier that day. ref SDS G8 PG6I
252800 - ..
252801 - Asked for the record performing Triamcinolone injection during EGD
252802 - procedure on 160816, noting letter to medical team presents
252803 - proposition that none was injected? ref SDS I2 BJ31
252805 - ..
252806 - During this part of the discussion, Doctor Lee left the meeting and
252807 - went to check a source not available on the computer next to the
252808 - gurney in the patient procedure preparation area. On returning, he
252809 - reported that on 160816, he injected the same 5 mL dose of
252810 - Triamcinolone that was administered on 160617.
252812 - ..
252813 - We reviewed the record of Triamcinolone 2 mL being effective for up to
252814 - 6 months maintaining LESV 16.5 mm, shown in case study on 160617 0800.
252815 - ref SDS G8 LD8O Research seems to indicate Triamcinolone 1.5 mL is a
252816 - standard adult dose, and that 2 - 3 mL has been commonly administered
252817 - in this case. This indicates 5 mL seems like a high dose that should
252818 - be avoided until determination that Triamcinolone did not cause
252819 - stroke symptoms on 160617.
252821 - ..
252822 - Doctor Lee seemed to say that Triamcinolone 5.0 mL was injected for
252823 - the procedure on 160816, in order to test the same regimen for
252824 - repetition of stroke symptoms that occurred on 160617.
252826 - ..
252827 - If that is correct, i.e., that Triamcinolone 5.0 mL was injected on
252828 - 160816, then since stroke symptoms did not follow that procedure,
252829 - Triamcinolone 5.0 mL injection seems less likely to have caused stroke
252830 - symptoms for the prior procedure on 160617, particularly given the
252831 - close proximity in time between injections of only 2 months. Never
252832 - before in patient history have steroids been injected this close in
252833 - time.
252835 - ..
252836 - Doctor Lee cited his Progress Notes saying no single factor caused
252837 - stroke symptoms on 160617, reported on 160812 1626. ref SDS H7 AQ43
252838 - Thus, subtle, conjuctive enabling forces were at work, discussed in
252839 - the letter to the team on 160621 1024. ref SDS H1 D457
252841 - ..
252842 - Asked to see Progress Notes for the procedure on 160816?
252844 - ..
252845 - Doctor Lee said Progress Notes for 160816, have not been signed,
252846 - because transcription contained so many errors, he has not had time to
252847 - make corrections required for signature.
252849 - ..
252850 - We decided to meet week after next (after Half Dome) to review
252851 - Progress Notes for procedure on 160816, and for EGD procedure today.
252852 -
252853 - [...below on 160909 0800 at 1124 after EGD procedure
252854 - Doctor Lee scheduled review meeting on 160921 1130.
252855 - ref SDS 0 4U5F
252857 - ..
252858 - Doctor Lee cited his earlier Progress Notes presenting theory that
252859 - multiple factors caused stroke symptoms following EGD on 160617,
252860 - reported on 160812 1626. ref SDS H7 AQ43
252862 - ..
252863 - Doing the math, adding another 5 mL on 160816, makes 10 mL in 2
252864 - months, and 13 mL in 5 months, which is more than 600% increase for
252865 - Triamcinolone typically required to maintain LESV for 6 months.
252867 - ..
252868 - Apart from potential neurological effects, steriods are commonly
252869 - associated with adverse side effects, including high blood pressure,
252870 - shortness of breath, weight gain, bloating, found in research on
252871 - 160617 0800. ref SDS G8 PG6I
252873 - ..
252874 - We need documentation on standard of care (i.e., Gold Standard) for
252875 - Triamcinolone injections into LESV to assess overdose, and what risks
252876 - arise with overdose, if any.
252878 - ..
252879 - Asked about implications of Progress Notes reporting approximate
252880 - quantities for Triamcinolone, see EGD on 160315 0900. ref SDS G6 OJ47
252882 - ..
252883 - The doctor advised that injecting Triamcinolone into LESV generally
252884 - results in excess quantity spilling out of each of several injection
252885 - sites along the perimeter of LESV. Seems this excess runs down the
252886 - throat into the stomach and through the digestion tract. Or, is
252887 - excess Triamcinolone suctioned out?
252889 - ..
252890 - Asked how patient can sign consent to a procedure that resulted in
252891 - stroke symptoms without any awareness of what caused symptoms how
252892 - medical team will avoid recurrence? At this time, everyone seems to
252893 - be in the dark, and so abundance of caution should be exercised using
252894 - conservative procedures.
252895 -
252897 - ..
252898 - Conscious Sedation Application May have Caused Stroke Symptoms 160617
252899 -
252900 - Doctor Lee seemed to indicate today, his sense that conscious sedition
252901 - was likely the primary cause of stroke symptoms on 160617. He could
252902 - say how this might have occurred on 160617, ref SDS G8 LD8O, and not
252903 - for 18 prior procedures in this case. Evidently, some subtle error
252904 - occurred that was not evident at the time. He feels that since prior
252905 - procedures on this patient and hundreds of others were performed
252906 - without adverse complications, the proper application of conscious
252907 - sedation today, should be safe today.
252909 - ..
252910 - Doctor Lee advised that he will reduce the dose of sedation medication
252911 - for the procedure today.
252913 - ..
252914 - He did not have Progress Notes available for the procedure on 160816,
252915 - to determine if this cautionary reduced sedation regimen was used at
252916 - that time.
252917 -
252918 -
252920 - ..
252921 - Swallowing Improved by Pantoprazole Resolving Ulceration LESV
252922 -
252923 - Letter to medical team yesterday on 160907, reported no swallowing
252924 - problems since EGD on 160816. ref SDS I2 BJ3T
252926 - ..
252927 - Doctor Lee was pleased, and explained swallowing may have improved
252928 - after EGD on 160816, despite no dilation with pneumatic baloon,
252929 - because...
252930 -
252931 - 1. LESV was dilated from 9.5 mm to 10 mm by advancing the
252932 - gastroscope through LESV, and because he...
252934 - ..
252935 - 2. Injected Triamcinolone 5 mL, and further because of...
252937 - ..
252938 - 3. Pantoprazole 40 mg twice per day was prescribed, and patient
252939 - added Baking Soda, beginning on 160902, shown in case study on
252940 - 140101 0600. ref SDS A9 W37L This combination significantly
252941 - resolved former ulceration, and this reduced ulceration
252942 - accounts for reduced resistance of LESV to swallowing, hence no
252943 - vomiting.
252945 - ..
252946 - Estimated LESV will engage today at < 9.5mm, based on having no
252947 - swallowing problems, and prior EGD on 160816 was LESV was dilated to
252948 - 10 mm solely from pressing gastroscope through LESV, due to severe
252949 - ulceration. ref SDS 0 RZ3G
252951 - ..
252952 - With these understandings, signed consent for the procedure, which is
252953 - not visible - there is merely a black screen to sign.
252954 -
252955 -
252956 -
252957 -
252959 - ..
2530 -
2531 -
2532 - 0922
2533 -
253301 - OR EGD Dilation with Application Lidocaine
253302 - EGD Dilation Procedure in OR Application Lidocaine
253303 -
253304 - Follow up ref SDS H8 7V6I, ref SDS G8 7V6I.
253305 -
253306 - Denise wheeled the gurney into the OR for the procedure.
253308 - ..
253309 - Everything went smoothly, as always.
253311 - ..
253312 - Doctor Lee made a point of reducing the amount of sedation drugs by
253313 - 50% today, per comment that sedation drugs seems most likely of all
253314 - the possibilities for having caused post-procedure stroke symptoms,
253315 - per above. ref SDS 0 GC4J He explained that patient seemed more
253316 - groggy after the procedure on 160816. Patient does not recall
253317 - elevated grogginess, i.e., it was less on 160816, than on 160617, and
253318 - previously on 151204.
253320 - ..
253321 - Before entering sleep for the procedure, discussed prospects that if
253322 - sedation drugs caused stroke symptoms it would seem to indicate
253323 - quantities were miss-entered in Progress Notes, since they seem
253324 - constant in all prior procedures, unlike Triamcinolone that shows wide
253325 - variance. ref SDS G8 LD8O
253326 -
253327 -
253328 -
253329 -
253331 - ..
2534 -
2535 -
2536 - 1305
2537 -
253701 - About 3 hours after procedure, still quite groggy. Just now felt
253702 - slight pinch in left eye. Testing seems to show both eyes seeing
253703 - equally, covering one then the other while view this computer screen.
253704 - So, no loss of vision as occurred OA 1630 on 160617. ref SDS G9 5F6F
253705 -
253706 -
253708 - ..
2538 -
2539 -
2540 - 0922 - continue
2541 -
254101 - Denise applied conscious sedation using the catheter which Connie set
254102 - in Preparation, per above. ref SDS H8 544G
254104 - ..
254105 - The team then did the EDG/dilation procedure.
254106 -
254107 -
254108 -
254110 - ..
254111 - Dilated 15 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee
254112 - Meeting Doctor Lee Present Results EGD Dilation Procedure 15 MM
254113 - Results EGD Dilation Procedure Meeting Doctor Lee Present 15 MM
254114 -
254115 - Follow up ref SDS H8 5H5J, ref SDS G8 5H5J.
2542 -
2543 -
2544 - 1124
254501 - ..
254502 - An hour or so after the procedure, met with Doctor Lee in the recovery
254503 - room.
254505 - ..
254506 - Doctor Lee advised that EGD examination today, found LESV remained at
254507 - 10 mm, the approximate size dilated during prior procedure on 160816
254508 - 0800. ref SDS H8 RZ3G
254510 - ..
254511 - This can be interpreted as relative success that LESV did not contract
254512 - below 10.0 mm, since past 2 procedures most recently on 160816, LESV
254513 - contracted from 15 mm back to 9.5, ref SDS H8 6P6G, and LESV
254514 - contracted similarly for EGD 2 months earlier on 160617 0800.
254515 - ref SDS G8 6P6G Hopefully, this "success" will lead to resolution of
254516 - continuing difficulties resulting from 2 month delay extending prior 6
254517 - month procedures to 8 months on 151204 0800. ref SDS F3 6P6G
254519 - ..
254520 - Doctor Lee advised that today, he injected triamcinolone 5 mL steroid
254521 - again, in order to restore and maintain swallowing.
254523 - ..
254524 - This seems somewhat risky following discussion this morning of
254525 - research showing overdose of Triamcinolone can cause vision loss, high
254526 - blood pressure, shortness of breath, weight gain, bloating, and
254527 - similar maladies commonly associated with over use of steroids, per
254528 - above. ref SDS 0 VN4O
254529 -
254531 - ..
254532 - LESV DILATE Triamcin Diphenhy Fenta Bena Midaz Lido
254533 - Months from - to olone Versed dramine nyl dryl olam caine
254534 - Interval Date mm mm mL mg mg mg mg mg mL
254535 - *1 0.75 160909 10 10......5.0.....3 ??...........250.....50...............5...... ref SDS 0 HU42
254536 - 2 160816 9.5 10......5.0.....6..............250.....50...............5...... ref SDS H8 HU42
254537 - 3 160617 9.5 15......5.0.....6..............250.....50...............5...... ref SDS G8 HU42
254538 - *2 4 160315 9.5 15......3.0............25......250.............5........5...... ref SDS G6 HU42
254539 - 8 151204 10 15......5.0............25......200.............5........5...... ref SDS F3 HU42
254540 - 6 150421 16.5 18......3.0............50......250.............4........5...... ref SDS D3 HU42
254541 - 6 141107 15 18......4.0............50......150.............5........5...... ref SDS C4 E54M
254542 - 6 140509 16.5 18.....................50......200.............5........5...... ref SDS B4 P680
254543 - 7 131115 16.5 18......2.0............50......200.............4........5...... ref SDS A6 RZ45
254544 - 3 130416 18 18......2.0.....5..............250.....50...............5...... ref SDS A0 Y850
254545 - 4 130110 15 18......3.0............50......100.............4........5...... ref SDS 95 Q333
254546 - *3 6 120925 15 18......4.0............50......200.............5........5...... ref SDS 87 XB51
254547 - 4 120322 16.5 18.....................50......150.............4........5...... ref SDS 84 516N
254548 - 3 111115 16.5 18.....................50......200.............4........5...... ref SDS 82 IR57
254549 - 4 110819 15 16.5....2.5............50......200.............5........5...... ref SDS 81 J978
254550 - 3 110429 13 16.5....3.5.....5..............200.....50...............5...... ref SDS 76 U23I
254551 - 3 110218 11 14......2.0............50......150.............4........5...... ref SDS 72 AA5O
254552 - 4 101210 11 14......................................................5...... ref SDS 67 H347
254553 - 5 100827 11 15..............5..............250.....50...............5...... ref SDS 55 JE6X
254554 - 3 100305 11 15..............5..............250.....50...............5...... ref SDS 48 WR6L
254555 - 091216 Heller Myotomy Fundoplication....................................... ref SDS 36 KE9U
254556 -
254558 - ..
254559 - Will be attentive for repeat of stroke symptoms.
254560 -
254561 -
254563 - ..
254564 - Ulceration LESV Decreased Enabled Dilating LESV
254565 -
254566 - Follow up ref SDS H8 RZ3G, ref SDS G8 RZ3G.
254567 -
254568 - Doctor Lee reported significantly improved ulceration LESV from prior
254569 - examination on 160816 0800. ref SDS H8 RZ3G He was able to dilate
254570 - LESV from 10.0 to 15 mm without damaging LESV due to improved
254571 - esophagitis (ulceration).
254573 - ..
254574 - Discharge documents show dilation 10 -> 15.
254576 - ..
254577 - This aligns with adding Baking Soda, and switching to Pantoprazole 40
254578 - mg twice per day, prescribed on 160816 0800, ref SDS H8 Q05K, and
254579 - ending Omeprazole 20 mg every other day, to prevent debilitating side
254580 - effects, discussed with Doctor Lee on 160315 0900, ref SDS G6 RZ3G;
254581 - and, further ending Famotidine to 20 mg twice per day, prescribed
254582 - during prior meeting with Doctor Lee on 160315 0900. ref SDS G6 ZQ4H
254583 -
254584 -
254586 - ..
254587 - Pantoprazole Prescirbed Replace Omeprazole and Famotidine
254588 -
254589 - Follow up ref SDS H8 Q05K.
254590 -
254591 - Doctor Lee prescribed continuing Pantoprazole 40 mg twice per day for
254592 - resolving increased esophagitis, and adding Baking Soda, as discussed
254593 - above. ref SDS 0 V77I
254594 -
254595 -
254597 - ..
254598 - Next Meeting 3 Weeks to Recover Severe Symptoms
254599 -
254600 - Follow up ref SDS H8 4U5F, ref SDS G8 4U5F.
254601 -
254602 - As requested during the meeting this morning, per above, ref SDS 0
254603 - K14N, Doctor Lee submitted notice showing review meeting is scheduled
254604 - on 160921 1130, to discuss Progress Notes for the meeting today,
254605 - receive and consider implications from prior procedure on 160816, and
254606 - plan adjustments to treatment protocol.
254608 - ..
254609 - Doctor Lee scheduled next EGD dilation in 3 weeks on 161004 0800.
254610 -
254611 -
254612 -
254613 -
254614 -
254615 -
254616 -
254617 -
2547 -
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 H8 CY7I, ref SDS G8 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 -
550907 -
550908 -
550909 -
550910 -
550911 -
550912 -
550913 -
550914 -
550915 -
550916 -
550917 -
550918 -
550919 -