CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10
2503 -
2503 - ..
2504 - Summary/Objective
2505 -
250501 - Follow up ref SDS K8 0000. ref SDS K4 0000.
250502 -
250503 - No diffuculty swallowing this cycle with LESV dilated to 18 mm 3 weeks
250504 - ago on 161213. ref SDS 0 VV6N Signed blank consent for the procedure
250505 - today, on assurance from Doctor Lee that stroke symptoms following
250506 - prior EGD on 160617, with mild recurrence 3 weeks ago on 161213, would
250507 - not recur. ref SDS 0 8744 Doctor Lee requested Neurology review of
250508 - left side eye deficits following prior EGD on 161213, and subsequent
250509 - examination by Eye Department at VA Clinic in Martinez 2 days ago on
250510 - 170104. ref SDS 0 HO8N EGD dilation procedure went smoothly, with no
250511 - reports of difficulties. ref SDS 0 7V6I Post procedure Doctor Lee
250512 - reported good results with LESV contracting to only 16.5 mm, and so he
250513 - dilated to 18 mm, the maximum for this protocol. ref SDS 0 433O
250514 - Ulceration improved over the past 3 weeks, which enabled the doctor to
250515 - dilate LESV needed for better swallowing. ref SDS 0 RZ3G New mild
250516 - ulceration area adjacent to LESV observed during prior EGD procedure
250517 - on 161213, was significantly improved today. ref SDS 0 W46M Doctor
250518 - Lee prescribed continuing Pantoprazole 40 mg and Famotidine 40 mg both
250519 - twice a day, and avoid Naproxen, required for hiking. ref SDS 0 Q05K
250520 - Scheduled next EGD dilation in 5 weeks. Decided no interim meeting
250521 - required to review progress and plan treatment for the periord ahead.
250522 - ref SDS 0 4U5F
250523 -
250524 -
250525 -
250526 -
250528 - ..
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 G7 P55L Reported using
251387 - baking soda to relieve reflux that prevents ulceration LESV; this
251388 - reduced Omeprazole in order to avoid dehydration. ref SDS G7 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 G7 PXXY EGD dilation procedure went smoothly, with no reports
251393 - of difficulties. ref SDS G7 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 G7 5H5J
251398 - ..
251399 - On 161128 1119 called VA GI Clinic in Sacramento; LaPreia said meeting
251400 - Doctor Lee scheduled for 161214, has been changed to the next day on
251401 - 161215 1200. ref SDS K0 OZ9G
251403 - ..
251404 - On 161205 0846 anonomous flowers and chocolates sent wishing GI staff
251405 - Merry Christmas and Happy New Year for doing terrific work.
251406 - ref SDS K3 FS5I
251407 -
251408 -
251409 -
251410 -
251411 -
251413 - ..
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 K8 NU8L, ref SDS K4 NU8L.
251806 -
251807 - Meeting today, was scheduled during meeting with Doctor Lee on 161215
251808 - 1100. ref SDS L3 C16M
251810 - ..
251811 - Performing EGD dilation 1 week after prior procedure on 161130 1038,
251812 - ref SDS K1 9V9J, represents continuing urgent, exigent care to recover
251813 - from severe contraction LESV 6 mm, worst condition in patient history,
251814 - found during procedure 2 weeks ago on, ref SDS J9 0001, 161122, and
251815 - which therefore prevented dilation above 12 mm, ref SDS J9 433O,
251816 - thereby requiring continued semi-liquid diet, and continuing interim
251817 - increased medication of Pantoprazole and Famotidine another week for
251818 - the purpose of resolving ulceration, and despite rising side effects
251819 - of frequent urination causing dehydration that injures feet,
251820 - preventing hiking required to raise HDL that regresses
251821 - atherosclerosis, reported ago on 161115. ref SDS J5 Q05K
251823 - ..
251824 - Additionally, pausing Naproxen to aid prevention of ulceration above
251825 - LESV, originally planned in the meeting on 161115 0800, ref SDS J5
251826 - 9K9G, and continued on 161122 1245, ref SDS J8 C26J, eliminates
251827 - suppression of inflammation in right knee, causing severe pain that
251828 - has limited hiking to just 2 6-mile hikes this week, most recently
251829 - yesterday on 161129, reported in case study on 160101 0700.
251830 - ref SDS G0 Z87H
251832 - ..
251833 - Applied pre-proc requirements for NPO after midnight, from letter on
251834 - 101015 1547. ref SDS 59 4J9L Last food was at......
251836 - ..
251837 - Drove to Sacramento last night. This morning, Kathy drove us to VA
251838 - Medical Center at Mather AFB in Sacrmento.
251840 - ..
251841 - At 1127, checked into GI Department at the customer counter..
251842 -
251843 - 800-382-8387
251844 -
251845 - 916 843 7000
251847 - ..
251848 - Kathy cell phone for designated driver...
251852 - ..
251853 - Kathy signed the discharge form affirming she will be designated
251854 - driver, and responsible to facilitate no driving for 24 hours.
251856 - ..
251857 - Nurse at customer counter asked questions on patient history to verify
251858 - ready for procedure, e.g., no allergies, and NPO after midnight to
251859 - avoid conflicts with anesthesia; no health problems, e.g., no
251860 - diabetes, alcohol, cigarettes.
251861 -
251862 -
251863 -
251864 -
251865 -
251867 - ..
2519 -
2520 -
2521 - 1133
2522 -
252201 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
252202 -
252203 - Follow up ref SDS K8 EP75, ref SDS K4 EP75.
252204 -
252205 - No objections nor concerns today, as occurred previously on 161115
252206 - 0800, ref SDS J5 WA5I, and again last week on 161130 1038. ref SDS K1
252207 - EP75
252209 - ..
252210 - Connie took vitals today, prior to procedure in a small office just
252211 - off the lobby, and not in the treatment center, reported on 120925
252212 - 0900. ref SDS 87 PT5P
252214 - ..
252215 - Vitals included...
252216 -
252217 - Weight.................. 190.0 (with shoes)
252218 - BP...................... 140 67
252219 - HR (pulse).............. 74
252220 - Oxygen.................. 98
252221 - Temp.................... 96.8
252222 -
252224 - ..
2523 -
2524 -
2525 - 1228
2526 -
252601 - Christi called me into the GI Prep area.
252603 - ..
252604 - Christi configured on gurney and connected equipment to monitor vitals
252605 - during the procedure.
252607 - ..
252608 - Dan set catheter IV for sedation. Required 1 stick today, in right
252609 - arm.
252611 - ..
252612 - Case study on sticks required to set catheter is reported on 110429
252613 - 1230. ref SDS 76 UO3G
252615 - ..
252616 - Christi went through patient identification and medical profile
252617 - filling out forms on the computer based on prior information 3 weeks
252618 - ago on 161213 0800. ref SDS K8 6Y8K
252620 - ..
252621 - She asked about pain? Reported level 0.
252622 -
252623 -
252625 - ..
2527 -
2528 -
2529 - 1320
2530 -
253001 - Waited about 40 minutes.
253002 -
253003 -
253005 - ..
253006 - Consent Signed EGD Dilation and Meeting Review Pending Issues
253007 - Consultation Pending Issues and Sign Consent for EGD Dilation
253008 -
253009 - Follow up ref SDS K8 RG9K, ref SDS K4 RG9K.
253010 -
253011 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation
253012 - procedure today.
253014 - ..
253015 - Noted that signature is entered on completely black screen, required
253016 - without reading online documents.
253018 - ..
253019 - Doctor Lee explained that over Christmas Holidays, he took his family
253020 - to Yosemite Valley. From the Valley floor, he showed his children
253021 - where one of his patients climbed to the top of Half Dome on 160914
253022 - 0530. ref SDS I6 0001
253024 - ..
253025 - Advised that signature is based on following understandings...
253027 - ..
253028 - Agenda Meeting Doctor Lee...
253030 - ..
253031 - 1. Schedule follow up meeting for EGD dilation today...
253032 -
253033 - Avoid meeting on 17013.
253035 - ..
253036 - Next EGD avoid 170123 - 27
253037 -
253039 - ..
253040 - 2. Mylanta - VA Pharmacy won't ship until 170109; inventory
253041 - already depleted.
253043 - ..
253044 - Doctor Lee planned to double dose, so can get needed quantity.
253046 - ..
253047 - Can Doctor Lee place a new order to ship today?
253048 -
253049 -
253051 - ..
253052 - 3. Naproxen liquid suspension requires doctor's prescription...
253053 -
253054 - CLINICAL PHARMACOLOGY
253055 -
253056 - Roxane Laboratories, Inc
253057 -
253058 - Rx only
253059 -
253060 - https://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=5701
253062 - ..
253063 - Naproxen oral suspension contains 125 mg naproxen per 5 mL.
253064 - In addition, the following inactive ingredients are present:
253065 - FD&C Yellow #6, fumaric acid, imitation orange flavor,
253066 - imitation pineapple flavor, magnesium aluminum silicate,
253067 - methylparaben, purified water, sodium chloride, sorbitol
253068 - solution and sucrose. It has a sodium content of 39.3 mg/5
253069 - mL, 1.71 mEq/5 mL, with a pH range of 2.2 to 3.7.
253071 - ..
253072 - Switching to liquid Naproxen would prevent pills from
253073 - accumulating on LESV causing severe recurrent ulceration,
253074 - reported on 160816 0800. ref SDS H9 RZ3G Continuing Naproxen
253075 - in liquid form would enable continuing extended endurance
253076 - exercise hiking 11 - 15 miles per day that raises HDL required
253077 - to regress atherosclerosis in order to maintain quality of
253078 - life, i.e., cardio pulmonary function, cognition, digestion,
253079 - immunity.
253081 - ..
253082 - On 161212 1632 Doctor Dang in Orthopedics at VAMCSF ordered
253083 - knee treatment with Synvisc. ref SDS K7 W579
253085 - ..
253086 - On 161222 0819 Doctor Tang prescribed diclofenac gel 1%,
253087 - (Voltaren), to replace Naproxen. 161222 0819, ref SDS L5 FM58
253088 - This eliminates toxic effects that previously caused
253089 - ulceration LESV.
253091 - ..
253092 - Doctor Lee was pleased that Doctor Tang in Podiatry Clinic at VA
253093 - Medical Center in San Francisco prescribed Diclofenac 1% (Voltaren)
253094 - Gel 12G and ordered on 161220 0927, ref SDS L4 0657, and because
253095 - Diclofenac is a gel applied topically rather than injested, and so
253096 - cannot cause ulceration on LESV, and further replaces Naproxen, that
253097 - is toxic and so suspected of causing ulceration on LESV, because the
253098 - pills get stuck in esophatus above contracted LESV.
253100 - ..
253101 - Doclofenac, however, is very messy and time consuming to apply.
253102 -
253104 - ..
253105 - 4. Ensure was ordered by Doctor Lee during prior procedure on
253106 - 161122 1245 at 1534, and to support nutriation on liquid diet,
253107 - while recovering from severe ulceration, and extreme
253108 - contraction of LESV. ref SDS J9 7440
253110 - ..
253111 - Gracy was commended because her revised prescription changing to
253112 - vanilla, was delivered after getting the original prescription with
253113 - chocolate.
253114 -
253116 - ..
253117 - 5. Eye examinaton on Wednesday, by Doctor Puckett in Eye
253118 - Department at VA Clinic in Martinez, reported on 170104 0900,
253119 - ref SDS L6 FG7I This eye examination was performed on referral
253120 - from Doctor Lee during post-procedure meeting on 161215 1100.
253121 - ref SDS L3 X15C
253123 - ..
253124 - Doctor Puckett seemed to say reaction to steriods would not
253125 - cause contraction of the pupil and pain from sunlight. He
253126 - further advised examination by the Eye clinic cannot assess
253127 - this condition driven by neurological factors. ref SDS L6 QL62
253129 - ..
253130 - Doctor Lee said he saw Doctor Puckett's Progress Notes reporting left
253131 - eye side effects after EGD procedure on 161213, ref SDS K8 R74J,
253132 - should be reviewed by Neurology, rather than eye clinic, to determine
253133 - precautions applying medications for conscious sedation.
253135 - ..
253136 - Doctor Lee asked patient to schedule meeting with Neurology at VAMCSF,
253137 - since they did the original work up on neurology side effects after
253138 - EGD dilation on 160617 1637. ref SDS H0 PPVV
253139 -
253140 -
253142 - ..
253143 - 6. Interim report on Peer Review.
253144 -
253145 - During meeting with Doctor Lee on 160921 1130, he indicated
253146 - Peer Review report on stroke symptoms following EGD on 160617,
253147 - was to have been presented to doctors conference earlier that
253148 - morning, but this didn't occur, because the doctor doing the
253149 - report was called away to perform emergency care at the time of
253150 - the meeting. ref SDS I7 QG6F
253152 - ..
253153 - On 161004, Doctor Lee said he has still not seen the report,
253154 - ref SDS I9 4W4N, despite notice during the meeting on 160921,
253155 - that the report has been completed. ref SDS I7 QG6F
253157 - ..
253158 - On 161019, Doctor Lee cited continued delays distributing
253159 - independent report on cause of stroke symptoms from procedure
253160 - on 160617. ref SDS J4 QG6F
253162 - ..
253163 - On 161122, Doctor Lee reported internal personnel problems have
253164 - caused extended administrative delays either completing several
253165 - reports of this kind, and/or delaying distribution. Doctor Lee
253166 - has notified VA management that the report on findings and
253167 - recommendations in the report on cause of stroke symptoms is
253168 - urgent for guiding continuing work. At this time status is
253169 - unknown. Doctor Lee will ask the Chief of Surgery for an
253170 - undate on getting at least an interim report from the doctor
253171 - assigned to perform Peer Review of stroke symptoms, ref SDS J8
253172 - 4W4N, that occurred following EGD dilation procecure on 160617.
253173 - ref SDS H0 5F6F
253175 - ..
253176 - Did not discuss this matter today.
253177 -
253179 - ..
253180 - 7. Review letter to medical team asking Doctor Massa to support
253181 - sedation medication regimen, shown on 161003 0628. ref SDS I8
253182 - WQ66
253184 - ..
253185 - Intravenous Medications
253186 - Diphenhydramine 25 mg (Benadryl)
253187 - Fentanyl 200 mcg
253188 - Midazolam 5 mg (Versed)
253190 - ..
253191 - Previously during the meeting on 161004 0800, showed the letter to
253192 - Doctor Lee because he no longer has an electronic address for
253193 - receiving correspondence to the medical team. ref SDS I9 554I
253195 - ..
253196 - At that time on 161004, Doctor Lee asked who is on the medical team
253197 - getting distribution of correspondence on this issue, ref SDS I9 W466,
253198 - and saw the list showing...
253199 -
253200 - Doctor Lee, GI
253201 - Doctor Massa, Neurology
253202 - Doctor Yoo, Neurology
253203 - Doctor Simpson, Cardiology
253204 - Doctor Stewart, General Surgery
253206 - ..
253207 - There was no discussion.
253208 -
253210 - ..
253211 - 8. 2nd opinion letter dated 160802, issued by Doctor Vora,
253212 - Attending, and Doctor Kim at Stanford Neuroscience, and
253213 - addressed to Doctor Massa in Neurology at VA Medical Center in
253214 - San Francisco, and with CC to Doctor Lee, and which was
253215 - received in the record on 160820 0940, ref SDS I1 R66J, and
253216 - which says in part...
253217 -
253218 - The diffuse leptomeningeal enhancement! increased
253219 - vascularity most prominent in a culprit right frontal
253220 - region raises question of anesthetic-related changes +/-
253221 - seizure, PRES, and less likely malignancy,
253222 - autoimmune/vasculitis, or infectious changes given bland
253223 - LP, patent's stability, and lack of headache. ref SDS I1
253224 - JF86
253226 - ..
253227 - On 161115, last week Doctor Lee took Stanford's bill of $855
253228 - and the 2nd opinion, both dated 160802, and made copies for his
253229 - use. He returned the originals, and advised that he will
253230 - incorporate these documents into patient Progress Notes for the
253231 - encounter today. Doctor Lee will further submit the bill of
253232 - $855 for payment to the patient. ref SDS J5 NW8O
253234 - ..
253235 - During the meeting on 161215, Doctor Lee showed that he entered
253236 - Stanford 2nd opinion letter dated 160802, into his Progress
253237 - Notes, following up submission to him during the meeting on
253238 - 161115 0800. ref SDS J5 NW8O However, somehow, Stanford's
253239 - billing for 2nd opinion work in the amount of $855, also
253240 - submitted on 161115, was not entered in the doctor's Progress
253241 - Notes.
253243 - ..
253244 - Today, re-submitted to Doctor Lee Stanford's billing of $855 for 2nd
253245 - opinion work on 160802 1300. ref SDS H4 9I7O The doctor plans to
253246 - enter it in his Progress Notes by addendum below Stanford Neuroscience
253247 - 2nd opinion. He asked that the bill be presented to Neurology in San
253248 - Francisco for payment. If this becomes problematic, he will try
253249 - getting payment approved in Sacramento.
253250 -
253252 - ..
253253 - 9. Conscious sedation drugs for anesthesia will not exceed amounts
253254 - that have previously not caused neurological deficits, as
253255 - occurred on 160617 1637, ref SDS H0 5F6F, and possible mild
253256 - recurrence involving left eye deficits on 161213 0800.
253257 - ref SDS K8 R74J
253259 - ..
253260 - We agreed that in signing the consent for the procedure today,
253261 - drugs will not be added above amounts that have previously not
253262 - caused neurological deficits (i.e., stroke symptoms). If the
253263 - procedure gets prolonged, as occurred on 160617 0800,
253264 - ref SDS G9 N16M, the patient will be allowed to drift out of
253265 - sedation in order to avoid increasing sedation drugs, and
253266 - because this patient may be biologically prone to over react to
253267 - excessive sedation drugs, reported on 161011 1330. ref SDS J1
253268 - P534 We further reviewed the record showing EGD dilation
253269 - procedure was performed entirely without sedation drugs, and
253270 - was successful on 101210 0930. ref SDS 67 PK8M
253272 - ..
253273 - Doctor Lee will closely monitor conscious sedation medications
253274 - in accordance with these understandings.
253275 -
253277 - ..
253278 - 10. Triamcinolone - less than 3 mL.
253279 -
253280 - We further discussed again limiting Triamcinolone steroid
253281 - injections to 3 mL, and in order to limit side effects of...
253282 -
253283 - Vison loss
253284 - High blood pressure
253285 - Weight gain
253286 - bloating
253288 - ..
253289 - This aligns with understandings during the meeting on 160921
253290 - 1130, ref SDS I7 TI3M, and again when meeting on for prior EGD
253291 - procedure last month on 161004 0800. ref SDS I9 VV6N
253293 - ..
253294 - What guides application of Triamcinolone?
253296 - ..
253297 - Has extreme contraction of LESV to 6 mm last week, reported on
253298 - 161122 1245, ref SDS J8 433O, resulted from reducing or
253299 - eliminating Triamcinolone?
253301 - ..
253302 - On 161130, Doctor Lee seemed to say today he has injected
253303 - Triamcinolone for the procedure 2 weeks ago on 161115, and for
253304 - all procedures this year, including last week on 161130. 161130
253305 - 1038, ref SDS K1 7M4K
253307 - ..
253308 - Ask about increasing Triamcialone to increase time LESV remains
253309 - expanded, based on amount of contraction today. The balance is
253310 - maintaining expansion of Triamcinalone, without accelerating
253311 - concentration week to week.
253312 -
253314 - ..
253315 - 11. Feet examined and found still normal, showing minimal effects
253316 - prescribing high dose Pantoprazole 40 mg twice-a-day, and
253317 - combined with increasing dose Ezetimibe 10 mg and Atorvastatin
253318 - 10 mg every other day, from every 3 days.
253320 - ..
253321 - Did not examine feet; was not enough time.
253323 - ..
253324 - Signed consent for the procedure, which is not visible - there is
253325 - merely a black screen to sign.
253326 -
253327 -
253328 -
253330 - ..
253331 - Swallowing Improved Vomitting Difficulties Decreased
253332 -
253333 - Follow up ref SDS K8 VV6N, ref SDS K4 VV6N.
253334 -
253335 - Reported no vomiting past 3 weeks with LESV dilated to 18 mm on 161213
253336 - 0800. ref SDS K8 LP4I
253338 - ..
253339 - Estimated LESV will engage today at 17 mm. Since there have been no
253340 - difficulties swallowing the past 3 weeks with semi-liquid diet.
253341 - Possible there has been no contraction, and LESV has remained at 18 MM
253342 - dilated on 161213 0800. ref SDS K8 LP4I Will be disappointing if
253343 - LESV contracts to 15 mm.
253345 - ..
253346 - Did not discuss today, increasing Triamcinalone slightly to maintain
253347 - LESV, i.e., prevent contraction going forward, that has occurred the
253348 - past 2 months, shown in case study last week on 161206 1130.
253349 - ref SDS K4 LP4I
253350 -
253351 - [...below on 170106 1200 at 1608 after EGD dilation
253352 - procedure today, Doctor Lee reported there was only 1 split
253353 - in LESV tissue, so he made only 1 injection of
253354 - Triamcinalone steroid, but it was 2 mL, which normally
253355 - would be enough for 2 splits; and so may help reduce
253356 - contraction of LESV over next 5 weeks until next EGD
253357 - procedure on 170210. ref SDS 0 433O
253358 -
253359 -
253361 - ..
2534 -
2535 -
2536 - 1344
2537 -
253701 - Complete pre-op and meeting with Doctor Lee
253702 -
253703 - Waiting for OR.
253704 -
253705 -
253706 -
253708 - ..
2538 -
2539 -
2540 - 1401
2541 -
254101 - OR EGD Dilation with Application Lidocaine
254102 - EGD Dilation Procedure in OR Application Lidocaine
254103 -
254104 - Follow up ref SDS K8 7V6I, ref SDS K4 7V6I.
254106 - ..
254107 - Everything went smoothly, as always.
254109 - ..
254110 - Christi applied conscious sedation using the catheter set by Dan
254111 - earlier in Preparation, per above. ref SDS K8 544G Assume
254112 - understandings were applied on sedation protocol reviewed with Doctor
254113 - Lee and agreed in signing the consent, per above. ref SDS K8 8744
254115 - ..
254116 - Did not get name of technical assistant today.
254118 - ..
254119 - The team then did the EDG/dilation procedure with Doctor Lee.
254120 -
254121 -
254122 -
254124 - ..
254125 - LESV Contract 6 MM Dilation 12 MM Ulceration Resolved
254126 - Meeting Doctor Lee Present Results EGD Dilation Procedure 12 MM
254127 - Results EGD Dilation Procedure Meeting Doctor Lee Present 12 MM
254128 - Liquid Diet Continue LESV Contracted 6 MM Worst in Patient History
254129 -
254130 - Follow up ref SDS K8 5H5J, ref SDS K4 5H5J.
2542 -
2543 -
2544 - 1608
2546 - ..
254601 - After the procedure, met with Doctor Lee in the recovery room.
254603 - ..
254604 - Doctor Lee reported better results again today. LESV contracted from
254605 - 18 mm down to 16.5 mm, showing considerable improvement compared to
254606 - recent severe weekly contractions the past several months, evident
254607 - from case study below. ref SDS 0 SP5G
254609 - ..
254610 - Doctor Lee dilated the opening to 18 mm (aligns with Discharge
254611 - Instructions saying Dilation 16.5 - 18 mm). Equally important,
254612 - only 1 split occurred expanding LESV to 18 mm. This reduced the
254613 - amount of Triamcinolone steroid injection required. Doctor Lee
254614 - injected 2 mL, which is high for 1 split, which may reduce the rate
254615 - of contraction, and also reduce severity of side effects.
254617 - ..
254618 - Bena
254619 - Versed/ dryl
254620 - LESV DILATE Triamcin Midaz Diphenhy Fenta Lido
254621 - Months from - to olone olam dramine nyl caine
254622 - Interval Date mm mm mL mg mg mg mL
254623 - 0.75 170106 16.5 18......2.0.....5......25......200......5.... ref SDS 0 433O
254624 - 0.25 161213 15 18......3.0.....5......25......200......5.... ref SDS K8 433O
254625 - 0.25 161206 11 16.5....1.0.....5......25......200......5.... ref SDS K4 433O
254626 - 0.25 161130 11 15......0.0.....5......25......200......5.... ref SDS K1 433O
254627 - 0.25 161122 6 12......0.0.....5......25......200......5.... ref SDS J9 433O
254628 - 1.50 161115 10 10......0.0.....5......25......200......5.... ref SDS J5 5H5J
254629 - 0.75 161004 11 15......5.0.....5......25......200......5.... ref SDS I9 HU42
254630 - 0.75 160909 10 15......5.0.....5......25......200......5.... ref SDS H9 HU42
254631 - 2 160816 9.5 10......5.0.....4......50......150......5.... ref SDS H9 HU42
254632 - 3 160617 9.5 15......5.0.....6......50......250......5.... ref SDS G9 HU42
254633 - 4 160315 9.5 15......3.0.....5......25......250......5.... ref SDS G7 HU42
254634 - 8 151204 10 15......5.0.....5......25......200......5.... ref SDS F3 HU42
254635 - 6 150421 16.5 18......3.0.....4......50......250......5.... ref SDS D3 HU42
254636 - 6 141107 15 18......4.0.....5......50......150......5.... ref SDS C4 E54M
254637 - 6 140509 16.5 18..............5......50......200......5.... ref SDS B4 P680
254638 - 7 131115 16.5 18......2.0.....4......50......200......5.... ref SDS A6 RZ45
254639 - 3 130416 18 18......2.0.....5......50......250......5.... ref SDS A0 Y850
254640 - 4 130110 15 18......3.0.....4......50......100......5.... ref SDS 95 Q333
254641 - 6 120925 15 18......4.0.....5......50......200......5.... ref SDS 87 XB51
254642 - 4 120322 16.5 18..............4......50......150......5.... ref SDS 84 516N
254643 - 3 111115 16.5 18..............4......50......200......5.... ref SDS 82 IR57
254644 - 4 110819 15 16.5....2.5.....5......50......200......5.... ref SDS 81 J978
254645 - 3 110429 13 16.5....3.5.....5..............200......5.... ref SDS 76 U23I
254646 - 3 110218 11 14......2.0.....4......50......150......5.... ref SDS 72 AA5O
254647 - 4 101210 11 14......................................5.... ref SDS 67 H347
254648 - 5 100827 11 15..............5......50......250......5.... ref SDS 55 JE6X
254649 - 3 100305 11 15..............5......50......250......5.... ref SDS 48 WR6L
254650 - - 091216 Heller Myotomy Fundoplication................. ref SDS 36 KE9U
254651 -
254652 -
254654 - ..
254655 - Conscious Sedation Reduced Dose Applied for 15 Minutes
254656 -
254657 - Follow up ref SDS K8 714N, ref SDS K4 714N.
254658 -
254659 - No discussion of conscious sedation during post-procedure meeting.
254661 - ..
254662 - Assume understandings were applied on sedation protocol reviewed with
254663 - Doctor Lee and agreed in signing consent for the procedure today, per
254664 - above. ref SDS K8 8744
254666 - ..
254667 - No post procedure side effects as occurred 3 weeks ago on 161213 0800.
254668 - ref SDS K8 R74J
254669 -
254670 -
254671 -
254673 - ..
254674 - Ulceration Improved Stricture Decreased
254675 -
254676 - Follow up ref SDS K8 RZ3G, ref SDS K4 RZ3G.
254677 -
254678 - Doctor Lee presented pictures showing results of examination today.
254679 - He advised that severe ulceration has continued to be completely
254680 - resolved. The prior ulceration hole adjacent to LESV opening in the
254681 - esophagus found during the procedure 7 weeks ago on 161115 0800,
254682 - ref SDS J5 K44N, and continuing remnants of ulceration found during
254683 - EGD procedure on 161122 1245, ref SDS J8 RZ3G, is still no longer
254684 - visible.
254686 - ..
254687 - Doctor Lee reported new mild ulceration has further subsided adjacent
254688 - to Lesv on other side and with wider area where prior severe
254689 - ulceration formed on 161115 0800. ref SDS J5 K44N Reduction of this
254690 - ulceration shows significant progress.
254692 - ..
254693 - This was a great relief, indicating effectiveness of Pantoprazole
254694 - prescribed beginning on 160816 0800, ref SDS H9 Q05K, and
254695 - particularly returning to 2 Pantoprazole each day, beginning on
254697 - ..
254698 - As a result, the doctor was able to dilate LESV from 16.5mm - 18mm,
254699 - shown in the table above. ref SDS 0 433O
254700 -
254701 -
254702 -
254704 - ..
254705 - Liquid Diet Increase Pantoprazole to Heal Ulceration LESV
254706 - Pantoprazole Increased with Famotidine and Baking Soda or Tumms
254707 -
254708 - Follow up ref SDS K8 Q05K, ref SDS K4 Q05K.
254709 -
254710 - Doctor Lee prescribed continuing high dose Pantoprazole 40 mg and
254711 - Famotidine 40 mg both twice a day for 5 weeks until next EGD
254712 - procedure.
254714 - ..
254715 - Doctor Lee feels Naproxen should be avoided entirely for next 5 weeks.
254716 - He feels reduced ulceration has been achieved in part by avoiding
254717 - Naproxen.
254719 - ..
254720 - The doctor was pleased that Doctor Tang in Podiatry in Podiatry Clinic
254721 - at VA Medical Center in San Francisco prescribed Diclofenac 1%
254722 - (Voltaren) Gel 12G and ordered on 161220 0927, ref SDS L4 0657, and
254723 - because Diclofenac is a gel applied topically rather than injested.
254724 -
254725 -
254727 - ..
254728 - Candidas Esophageal Infection Reduced by
254729 -
254730 - Follow up ref SDS K8 A23L, ref SDS K4 A23L.
254731 -
254732 - No discussion of candidas today.
254733 -
254735 - ..
254736 - Vocal Chords swollen
254737 -
254738 - Follow up ref SDS K8 FH6N, ref SDS K4 FH6N.
254739 -
254740 - No discussion of vocal chords today.
254741 -
254742 -
254744 - ..
254745 - Next Meeting 5 Weeks to Recover Severe Symptoms
254746 -
254747 - Follow up ref SDS K8 4U5F, ref SDS K4 4U5F.
254748 -
254749 - Doctor Lee extended perior to next EGD dilation from 3 to 5 weeks.
254750 -
254751 - [On 170109 0907 talked Gracie; she will coordinate with
254752 - Jessica on scheduling next EGD OA 170210. ref SDS L7 7640
254754 - ..
254755 - He said Jennifer will send notice of the date.
254756 -
254757 - [On 170113 1129 letter from Jessica saying next EGD
254758 - procedure scheduled on 170221 0800, ref SDS L8 HR9N
254760 - ..
254761 - Decided to defer planning meeting for this cycle.
254762 -
254763 -
254764 -
254765 -
254766 -
254767 -
2548 -
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 K8 CY7I, ref SDS K4 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/track-health
550412 -
550413 -
550420 - ..
550421 - On January 13, 2017, checked for Progress Notes for EGD on 161213, and
550422 - on 170106, and found they have not yet been posted for patient access.
550423 -
550424 -
550425 -
550426 -
550908 -
550909 -
550910 -
550911 -
550912 -
550913 -
550914 -
550915 -
550916 -
550917 -
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550919 -
550920 -
5510 -