THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com
S U M M A R Y
DIARY: July 11, 2017 08:00 AM Tuesday;
Rod Welch
VA EGD dilate LESV from 17mm to 19 mm add triamcinalone 1 mL injection per split.
1...Summary/Objective
2...Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
3...GI Department VA Sacramento Medical Center Administration EGD Dilation
4...Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
5...Consent Signed EGD Dilation and Meeting Review Pending Issues
6...Consultation Pending Issues and Sign Consent for EGD Dilation
7...Swallowing Improved Vomitting Difficulties Decreased
8...OR EGD Dilation with Application Lidocaine
9...EGD Dilation Procedure in OR Application Lidocaine
10...LESV Contract 6 MM Dilation 12 MM Ulceration Resolved
11...Meeting Doctor Lee Present Results EGD Dilation Procedure 12 MM
12...Results EGD Dilation Procedure Meeting Doctor Lee Present 12 MM
13...Liquid Diet Continue LESV Contracted 6 MM Worst in Patient History
14...EGD Chart Correlate Time Dilation Triamcinalone Sedation Drugs
15...Conscious Sedation Reduced Dose Applied for 15 Minutes
16...Ulceration Improved Stricture Decreased
17...Schedule Next Procedure and Post Procedure Review
18...Release of Information ROI CD Contents Received on 151224
..............
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CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10
2503 -
2503 - ..
2504 - Summary/Objective
2505 -
250501 - Follow up ref SDS N4 0000. ref SDS M8 0000.
250502 -
250503 - ********************************************
250504 - ********************************************
250505 -
250530 -
250531 -
250533 - ..
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 111201 0928 seems to be 10% increase in blood pressure the past
251120 - month, ref SDS 83 ZM5H, beginning on 111030, shown by case study on
251121 - 101010 0744. ref SDS 57 UT6K Case study reports Omeprazole paused on
251122 - 111201. ref SDS 57 734L
251124 - ..
251125 - On 120322 1030 notified Doctor Lee during meeting at VA changed dose
251126 - for Omeprazole to reduce sudden increase from low to high blood
251127 - pressure. ref SDS 85 UH5F
251129 - ..
251130 - On 120322 1030 EGD dilation procedure - swallowing and vomitting problems
251131 - increased without triamcinolone steriod injections on prior 3 month
251132 - cycle. ref SDS 85 UI9H LESV dilated from 16.5 - 18 mm. ref SDS 85
251133 - 516N Triamcinolone injections to resist contraction of LESV was not
251134 - performed. ref SDS 85 5179
251136 - ..
251137 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA
251138 - business unit; reported patient history. ref SDS 88 RG9K Scheduled
251139 - EGD and dilation procedure for 1300; returned and performed procedure,
251140 - ref SDS 88 TB4J; dilated from 15 mm to 18 mm. ref SDS 88 XB51
251141 - Swallowing and vomitting problems increased after omitting
251142 - triamcinolone steriod injections to resist contraction of LESV after
251143 - dilation, ref SDS 88 TZ4M; therefore, injections were resumed to
251144 - complement dilation to enable and maintain effective swallowing.
251145 - ref SDS 88 R87N
251147 - ..
251148 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found
251149 - improvement recovering from acalasia, LESV contracted only slightly
251150 - from 18 mm down to 15 mm. ref SDS 96 Q333
251152 - ..
251153 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV
251154 - remained at 18 MM, ref SDS A1 CO5N, same as dialated 4 months earlier
251155 - on 130110 0900. ref SDS 96 Q333 Report CT test on 130117, shows
251156 - esophagus fully recovered from severe distortions caused by achalasia
251157 - 8 years earlier. ref SDS A1 MT6F Doctor Lee injected steriod again to
251158 - maintain swallowing. ref SDS A1 F38G Prescribed reducing Omeprazole
251159 - to 1 pill per day. ref SDS A1 R74M Scheduled next EDG dilation in 6
251160 - months, instead of 3. ref SDS A1 6P6G
251162 - ..
251163 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5
251164 - to 18 mm. ref SDS A7 CO5N Triamcinolone steriod injected again to
251165 - maintain improved swallowing. ref SDS A7 I167 Omeprazole medication
251166 - maintained 20 mg taken morning and evening for 1 month, then reduce to
251167 - 20 mg once per day. ref SDS A7 R74M Biopsies taken. ref SDS A7 3N8L
251169 - ..
251170 - On 131121 1604 ordered refill of Omeprazole to aid digestion. There
251171 - is 1 refill remaining. ref SDS A8 YS4O
251173 - ..
251174 - On 131205 1443 received order for Omeprazole prescription placed on
251175 - 131121. ref SDS A9 5N3O
251177 - ..
251178 - On 140318 1043 received letter cancelling meeting scheduled for
251179 - EGD/Dilation procedure on 140425 1000, ref SDS B2 935L; a second
251180 - letter scheduled prodedure on 140509 0900. ref SDS B2 5D7H
251182 - ..
251183 - On 140401 1659 ordered refill Omeprazole; none are remaining; need
251184 - Doctor Lee to order new prescription to increase refills. ref SDS B3
251185 - 4P5M
251187 - ..
251188 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical
251189 - center in Sacramento, Mather. ref SDS B5 K37G Pre-op preperation went
251190 - well - IV setup on first stick. ref SDS B5 EP75 Doctor ordered refills
251191 - for Omeprazole. ref SDS B5 AW5O Doctor patient partnership continues
251192 - to progress with doctor reading up on patient history to be prepared
251193 - for effective meeting. ref SDS B5 ZZ6J Doctor Lee recalled today
251194 - having made timely referral for having heart surgery, enabling patient
251195 - to recover and Half Dome 4 years later. ref SDS B5 0N6I Reported
251196 - swallowing and vomitting problems reduced past 6 months with
251197 - triamcinolone steriod injections to resist contraction of LESV.
251198 - ref SDS B5 VV6N Doctor Lee dilated LESV contracted to only 16.5 MM
251199 - over past 6 months with triamcinolone steriod injections to resist
251200 - contraction; he dilated LESV back to 18 MMy, ref SDS B5 5H5J, scheduled
251201 - next EGD dilation in 6 months since this worked well the past 6 months
251202 - with triamcinolone steriod injections. ref SDS B5 549I The doctor
251203 - explained that since there was no tearing of LESV during procedure
251204 - today, triamcinolone steriod was not injected into LESV to resist
251205 - contraction. ref SDS B5 I167 Progress notes report small tearing of
251206 - LESV during dilation procedure. ref SDS B5 P680
251208 - ..
251209 - On 140718 1017 planning for notifying VA to update current fill date
251210 - for Omeprazole. ref SDS B9 U88L Kathy visited VA in Sacramento, and
251211 - requested changing refill date for Omeprazole to 140718. ref SDS B9
251212 - OL5K VA representative called customer, and said Doctor Lee would
251213 - call back later that day to consider action on updating scheduled
251214 - refill date of Omeprazole to 140718. ref SDS B9 U76M
251216 - ..
251217 - On 140810 1839 letter to Doctor Lee requesting EGD dilation with
251218 - triamcinolone injection soonest, if cancellation occurs; but, not an
251219 - emergency, ref SDS C1 W83K, based on history rising vomitting
251220 - swallowing problems, shown in patient history case study on 120101,
251221 - beginning 140712. ref SDS 84 4E4M
251223 - ..
251224 - On 140819 0800 during meeting at VA Primary Care Clinic in Martinez,
251225 - Doctor Sandhu indicated Doctor Lee at VA Medical Center in Sacramento
251226 - will be notified about rising achalasia symptoms for consideration to
251227 - advance EGD dilation procedure. ref SDS C2 EX78
251229 - ..
251230 - On 141014 0943 Kathy visited VA Medical Center in Sacramento and met
251231 - with Lapria again, who advised that the VA responded in a letter on
251232 - 141001, to the letter on 140810, and further scheduled a meeting with
251233 - Doctor Lee on 141121 1530. ref SDS C3 QJ5N
251235 - ..
251236 - On 141103 2152 submitted agenda for meeting with Doctor Lee at VA
251237 - Sacramento Medical Center on 141107 0800, for next EGD dilation.
251238 - ref SDS C4 K37G Submit record showing normal swallowing occurs longer
251239 - with triamcinolone steriod injection to resist contraction of LESV.
251240 - ref SDS C4 3U97 Request schedule next EGD dilation in 4 months, and
251241 - if LESV does not contract, then schedule following EGD dilation in 6
251242 - months. ref SDS C4 3U66 Notified results of Half Dome hike.
251243 - ref SDS C4 3U6Y
251245 - ..
251246 - On 141107 0800 EGD dilation procedure - setting IV for conscious
251247 - sedation required 3 sticks. ref SDS C5 5W5I Meeting Doctor Lee guided
251248 - by agenda facilitated collaboration through doctor patient
251249 - partnership. ref SDS C5 VV6N Doctor explained increased difficulty
251250 - swallowing due to experiment omitting triamcinalone steriod injection
251251 - on prior procedure, ref SDS C5 4U8I, shown by LESV contracting back to
251252 - from 15 mm. ref SDS C5 T55I Progress Notes report finding ulceration
251253 - and hiatal hernia. ref SDS C5 MG6N Photographs seem to show
251254 - significantly different condition of fundoplication from a year
251255 - earlier. ref SDS C5 I74I
251257 - ..
251258 - On 150319 0800 meeting Doctor Lee in GI Clinic VA Medical Center
251259 - Sacramento report swallowing improved with triamcinalone steriod
251260 - injections on 141107 EGD dilation procedure. ref SDS D1 0M6I Doctor
251261 - Lee advised that increased orange juice consumption aids digestion,
251262 - and presents no health risks. ref SDS D1 YF5M Scheduled next EGD
251263 - dilation procedure on 150421 1300. ref SDS D1 PS4O Fundoplication
251264 - failure increases acid burn that caused ulceration with hiatal hernia
251265 - with increased recurrance achalasia. ref SDS D1 O56O Doctor Lee will
251266 - make referral to Doctor Stewart at General Surgery VA Medical Center
251267 - in San Francisco for consideration of "redo" fundaplicaiton.
251268 - ref SDS D1 JQ5J Doctor Lee completed Progress Notes for EGD dilation
251269 - on 141107. ref SDS D1 PS53 Doctor Lee will recommend Doctor Stewart
251270 - order CT test to evaluate recurrance achalasia due to failure
251271 - fundoplication. ref SDS D1 TH5M This test can include coronary CTA to
251272 - evaluate regression atherosclerosis. ref SDS D1 GB56
251274 - ..
251275 - On 150420 1752 submitted letter to Doctor Lee with agenda for meeting
251276 - the next day on 150421 1300 for EGD dilation. ref SDS D3 0M6I
251278 - ..
251279 - On 150421 Met with Doctor Lee at VA Medical Center in Sacramento
251280 - (Mather). ref SDS D4 K37G No difficulties setting IV for conscious
251281 - sedation. ref SDS D4 5W5I Reported pain level 2 right knee MCL.
251282 - ref SDS D4 LO9K Doctor Lee advised referral to San Francisco will be
251283 - filed after EDG dilation procedure (this day) to evaluate loosening
251284 - fundoplication. ref SDS D4 DZ4I Patient reported difficulty
251285 - swallowing this cycle did not occur until 4 weeks or so, because
251286 - triamcinalone steriod was injected during prior procedure on 141107,
251287 - ref SDS D4 P55L, and shown by EGD dilation LESV from 16.5 mm back to
251288 - 18 mm. ref SDS D4 HU42 Progress Notes report findings of hiatal
251289 - hernia. ref SDS D4 QD6O Impression today that ulceration has subsided
251290 - to mere errosions seems promising. ref SDS D4 PXXY
251292 - ..
251293 - On 150514 0130 letter to Doctor Lee requests file Progress Notes for
251294 - EGD Dilation today, and make referral to Doctor Stewart, to prepare
251295 - for meeting with Doctor Lee scheduled on 150521. ref SDS D6 K37G
251297 - ..
251298 - On 150521 0800 meeting with Doctor Lee at VAMC in Sacramento -
251299 - concensus uncharacteristic vomitting after recent EGD dilation
251300 - procedure on 150421, due to patient not eating slowly with small bites
251301 - and drinking liquids frequently, especially when eating meat products
251302 - that have high viscocity with esophageal tissue, and so tends to
251303 - stick, causing vomitting. ref SDS D8 WT9L
251305 - ..
251306 - On 150526 1300 meeting with Doctor Stewart Chief General Surgery VA
251307 - Medical Center San Francisco, review record indicating ulceration LESV
251308 - caused by reflux backwash into esophagus. ref SDS D9 3E4I Doctor
251309 - Stewart explained redo Dor Fundoplication required for "repairing"
251310 - original surgery, presents high risk of collateral damage. ref SDS D9
251311 - GT5G Considered increase dose Omeprazole (PPI) since ad hoc
251312 - experience occasionally taking 3 and sometimes 4 pills instead of only
251313 - 1 pill per day seemed to reduce reflux based on examination showing
251314 - ulceration of LESV declined; this would avoid need to redo Dor
251315 - Fundoplication. ref SDS D9 5Y4I
251317 - ..
251318 - On 150616 1624 received photographs on CD in word.docx file from
251319 - Phillip in ROI Department at VA MC in Sacramento (Mather) showing Dor
251320 - fundoplication in tact on 131115, beginning to unravel on 140507,
251321 - further unraveled on 141107, and unraveled on 150421. ref SDS E2 XW6M
251323 - ..
251324 - On 150623 1300 during follow up meeting, Doctor Stewart discussed
251325 - again increasing Omeprazole PPI to resolve ulceration of LESV rather
251326 - than risk difficult surgery to redo Dor fundoplication, and she
251327 - ordered prescription for H2 blocker to supplement Omeprazole PPI.
251328 - ref SDS E3 WW5K
251330 - ..
251331 - On 150624 0924 letter notified Doctor Lee of work plan to try
251332 - controlling ulceration of LESV by increasing PPI with Omeprazole
251333 - rather than chance performing high risk surgery to repair Dor
251334 - fundoplication, and that Doctor Stewart ordered H2 Blocker for Doctor
251335 - Lee to consider supplementing PPI to control acid reflux. ref SDS E4
251336 - OP91
251338 - ..
251339 - On 150624 0924 at 1344 Doctor Lee called and will order new
251340 - prescription for PPI increasing Omeprazole from 20 mg twice per day to
251341 - 40 mg twice per day. ref SDS E4 L861
251343 - ..
251344 - On 150925 0336 request switch back to Omeprazole 20 mg twice per day
251345 - in order to reduce severe side effects of dehydration from frequent
251346 - urination causing scaling, peeling, bleeding feet; lower dose
251347 - Omeprazole enables hiking to raise HDL required to regress
251348 - atherosclerosis plaques, thereby lowering risks of CVD and CAD.
251349 - ref SDS E6 5G8T As a result, Pharmacy VA Medical Center San Francisco
251350 - entered new prescription for (PPI) Omeprazole 20 mg. ref SDS E6 FK66
251352 - ..
251353 - On 150925 0336 VA scheduled next meeting for EGD dilation on 151204
251354 - 0800. ref SDS E6 SR6L
251356 - ..
251357 - On 151002 1820 Doctor Lee returned call; will order Omeprazole 20 mg
251358 - prescription sufficient until next EGD Dilation procedure on 151204,
251359 - and complimenting prescription entered on 150925 for only 1 month.
251360 - ref SDS E7 NV5I
251362 - ..
251363 - On 151012 1151 VA Internet Pharmacy lists updated Omeprazole 20 mg
251364 - prescription. ref SDS D5 0C5H
251366 - ..
251367 - On 151204 0800 met with Doctor Lee at VA Medical Center in Sacramento
251368 - (Mather); initial administration went well. ref SDS F4 GD4H
251369 - Preparation for the procedure was professional; no difficulties
251370 - setting IV for conscious sedation today. ref SDS F4 544G The doctor
251371 - reported not receiving letter with agenda for the meeting today,
251372 - submitted on 151201. ref SDS F4 VV6N Patient difficulty swallowing
251373 - occurred after 5 months, because triamcinalone steriod injected prior
251374 - procedure on 150421. Swallowing difficulty/vomiting increased over
251375 - the next 3 months indicates dilate LESV 18 mm and doing EGD dilation
251376 - in 6 rather than 8 months. ref SDS F4 P55L Asked about Baking Soda to
251377 - clear throat in order to avoid vomitting, and prevent ulceration LESV
251378 - alternative to Omeprazole in order to avoid side effects causing
251379 - dehydration. ref SDS F4 G53K Performing EGD dilation procedure went
251380 - smoothly, with no difficulties. ref SDS F4 7V6I Post procedure Doctor
251381 - Lee reported LESV contracted to 10 mm, the worst results in patient
251382 - history, indicating 2 month delay performing procedure this cycle was
251383 - harmful. ref SDS F4 5H5J
251385 - ..
251386 - On 151210 meeting Doctor Lee after EGD on 151204, changed prescription
251387 - of Omeprazole (PPI) to 20 mg every other day to eliminate or reduce
251388 - dehydration from frequent urination, and in order for feet to recover
251389 - from peeling, cracking, bleeding so that hiking can be performed at
251390 - level of 300 miles per month required to raise HDL > 60, required to
251391 - regress athersclerosis. ref SDS F7 J56O Doctor prescribed adding
251392 - Famotidine an H2 blocker taken once a day to compliment Omeprazole.
251393 - ref SDS F7 YL3M
251395 - ..
251396 - On 160325 0900 Diffuculty swallowing this cycle began about 1 month
251397 - after prior EGD dilation on 151204. ref SDS G8 P55L Reported using
251398 - baking soda to relieve reflux that prevents ulceration LESV; this
251399 - reduced Omeprazole in order to avoid dehydration. ref SDS G8 Z84H
251400 - Progress Notes report there is no longer any erosive esophagitis and
251401 - there is no evidence of mass effect, which implies better acid
251402 - suppression compared to previous examination December 2015.
251403 - ref SDS G8 PXXY EGD dilation procedure went smoothly, with no reports
251404 - of difficulties. ref SDS G8 7V6I Post procedure Doctor Lee reported
251405 - LESV contracted to 9.5 mm, the smallest in patient history, indicating
251406 - 2 month delay to 8 months performing procedure in December causing
251407 - continual injury. ref SDS G8 5H5J
251409 - ..
251410 - On 161128 1119 called VA GI Clinic in Sacramento; LaPreia said meeting
251411 - Doctor Lee scheduled for 161214, has been changed to the next day on
251412 - 161215 1200. ref SDS K2 OZ9G
251414 - ..
251415 - On 161205 0846 anonomous flowers and chocolates sent wishing GI staff
251416 - Merry Christmas and Happy New Year for doing terrific work.
251417 - ref SDS K5 FS5I
251418 -
251419 -
251420 -
251421 -
251422 -
251424 - ..
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 N4 NU8L, ref SDS M8 NU8L.
251806 -
251807 - Meeting today, was scheduled during meeting with Doctor Lee on 170516
251808 - 0800. ref SDS N4 XF6X
251810 - ..
251811 - Performing EGD dilation 8 weeks after prior procedure on 170516 0800,
251812 - ref SDS N4 NU8L, represents continuing improvement recovering from
251813 - severe contraction LESV 6 mm, worst condition in patient history,
251814 - found during procedure on 161122, ref SDS K1 0001, and which prevented
251815 - dilation above 12 mm, ref SDS K1 433O, thereby requiring continued
251816 - semi-liquid diet, and continuing interim increased medication of
251817 - Pantoprazole (PPI) and Famotidine for the purpose of resolving
251818 - ulceration, and despite rising side effects of frequent urination
251819 - causing dehydration. During this cycle, Pantoprazole was reduced 50%
251820 - from 80 down to 40 mg per day, after 4 weeks, planned during prior
251821 - meeting on 170516 0800. ref SDS N4 9H8L Over the past 4 weeks,
251822 - reduced PPI medication lowered blood pressure. It further improved
251823 - dehydration by reducing frequent urination. The past 4 weeks improved
251824 - dehydration reduced severe feet injuries enabling increased hiking
251825 - required to raise HDL, which is essential to regress atherosclerosis,
251826 - reported ago on 161115. ref SDS J7 Q05K
251828 - ..
251829 - Applied pre-proc requirements for NPO after midnight, from letter on
251830 - 101015 1547. ref SDS 59 4J9L Last food was at......
251832 - ..
251833 - Drove to Sacramento on Sunday, reported on 170514 1230. ref SDS N1
251834 - 0O5I This morning, Kathy drove us to VA Medical Center at Mather AFB
251835 - in Sacrmento.
251837 - ..
251838 - At 0720, checked into GI Department at the customer counter..
251839 -
251840 - 800-382-8387
251841 -
251842 - 916 843 7000
251844 - ..
251845 - Kathy cell phone for designated driver...
251849 - ..
251850 - Kathy signed the discharge form affirming she will be designated
251851 - driver, and responsible to facilitate no driving for 24 hours.
251853 - ..
251854 - Nurse at customer counter asked questions on patient history to verify
251855 - ready for procedure, e.g., no allergies, and NPO after midnight to
251856 - avoid conflicts with anesthesia; no health problems, e.g., no
251857 - diabetes, alcohol, cigarettes.
251858 -
251859 -
251860 -
251861 -
251862 -
251864 - ..
2519 -
2520 -
2521 - 0738
2522 -
252201 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
252202 -
252203 - Follow up ref SDS N4 EP75, ref SDS M8 EP75.
252204 -
252205 - No objections nor concerns today, as occurred previously on 161115
252206 - 0800, ref SDS J7 WA5I, and again last week on 161130 1038. ref SDS K3
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 preparation area, reported on
252212 - 120925 0900. ref SDS 88 PT5P
252214 - ..
252215 - Vitals found...
252216 -
252217 - Weight.................. 185.0
252218 - BP...................... 132 63
252219 - HR (pulse).............. 77
252220 - Oxygen.................. 97
252221 - Temp.................... 98
252222 -
252223 -
252225 - ..
2523 -
2524 -
2525 - 0746
2526 -
252601 - Connie took me into the GI Prep area.
252603 - ..
252604 - Gracy configured on gurney and connected equipment to monitor vitals
252605 - during the procedure.
252607 - ..
252608 - Grace set catheter IV for sedation. Required 1 stick today, in right
252609 - arm. This reflects no needle sticks for 2 months. Veins develop
252610 - adhesions (scar tissue) and take time to heal, and prevent blood flow
252611 - into the IV needle.
252613 - ..
252614 - Case study on sticks required to set catheter is reported on 110429
252615 - 1230. ref SDS 76 UO3G
252617 - ..
252618 - Gracy went through patient identification and medical profile filling
252619 - out forms on the computer based on prior information 3 weeks ago on
252620 - 161213 0800. ref SDS L0 6Y8K
252622 - ..
252623 - She asked about pain? Reported level 0.
252624 -
252625 -
252626 -
252627 -
252628 -
252630 - ..
2527 -
2528 -
2529 - 0819
2530 -
253001 - Consent Signed EGD Dilation and Meeting Review Pending Issues
253002 - Consultation Pending Issues and Sign Consent for EGD Dilation
253003 -
253004 - Follow up ref SDS N4 KT9M, ref SDS M8 KT9M.
253005 -
253006 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation
253007 - procedure today.
253009 - ..
253010 - He arrived earlier today.
253012 - ..
253013 - Noted that signature is entered on completely black screen, required
253014 - without reading online documents.
253016 - ..
253017 - Advised that signature is based on following understandings...
253019 - ..
253020 - Agenda Meeting Doctor Lee...
253022 - ..
253023 - 1. Follow up meeting for EGD dilation today, is scheduled on
253024 - 170719, and was scheduled previously on 170516 0800.
253025 - ref SDS N4 BM5O
253027 - ..
253028 - 2. Orthopedic issues improving enabled increased hiking that aids
253029 - digestion and raises HDL.
253031 - ..
253032 - Knees doing well, reported to medical team on 170510 0917.
253033 - ref SDS N0 YL3U
253035 - ..
253036 - Feet better - metatarsalgia at moment is resolved, also
253037 - reported to team on 170510 0917. ref SDS N0 YL3Y
253039 - ..
253040 - Plantar plate tear long toe right foot - had to end
253041 - plantarflexion care due to significant trauma to long toe.
253042 - Doctor Tang ordered new orthotics on 170623 0830. ref SDS N5
253043 - M23H Scheduled to be received late August, early September.
253045 - ..
253046 - Scheduled meet Doctor Marc Darrow in Los Angeles on Monday,
253047 - 170717 1500 for consideration of PRP and/or stem cell
253048 - treatment for "regenerative treatment" to enable training for
253049 - Half Dome.
253051 - ..
253052 - 3. Ensure - effective taking 2 Pantoprazole pills per day; end
253053 - prescription on lowering Pantoprazole to 1 40 mg pill per day.
253054 -
253056 - ..
253057 - 4. Pantoprazole - effectiveness taking 1 40 mg pill per day,
253058 - beginning on 170615, shown in case study beginning on 160101
253059 - 0700. ref SDS G1 YS7H
253061 - ..
253062 - Order prescription refill - currently none are available.
253063 - Have enough for maybe 4 months.
253065 - ..
253066 - Assess today, toward maintaining reduced does, or increase
253067 - dose on findings of ulceration LESV recurrance.
253069 - ..
253070 - Frequent urination resolved - getting up 0 - 2 times per
253071 - night.
253073 - ..
253074 - Feet no longer dehydrated. Doctor Lee made examination and
253075 - found feet are now smooth and soft after lowering PPI from 80
253076 - to 40 mg per day, that reduces dehydration by reducing
253077 - frequent urination.
253079 - ..
253080 - Blood pressure much lower, shown in vitals this morning, per
253081 - above. ref SDS 0 5W4J
253083 - ..
253084 - Will review reduced blood pressure during follow up meeting on
253085 - 170719.
253087 - ..
253088 - Study on proton pump inhibitor (PPI) requested by Doctor Lee on
253089 - 170301 1200, ref SDS M4 A89F, was completed on 170331 1400.
253090 - ref SDS M7 UD4G
253091 -
253092 - F:\05\00003\SM\CC\CHMG\FNGC\CJGK\achalasia_meds_lesv.xlsx
253094 - ..
253095 - Blood pressure added to study, requested by Doctor Lee on
253096 - 170419 0900. ref SDS M9 HJ7K
253097 -
253099 - ..
253100 - 5. Interim report on Peer Review.
253101 -
253102 - On 160714 0814 Doctor Lee called and advised that he ordered
253103 - independent review, ref SDS H3 GL8O, of EGD dilation procedure
253104 - performed on 160617 0800, ref SDS H0 0001, to determine why
253105 - stroke symptoms occurred after the procedure, also reported on
253106 - 160617 1637. ref SDS H1 5F6F
253108 - ..
253109 - On 161122, Doctor Lee reported internal personnel problems have
253110 - caused extended administrative delays either completing several
253111 - reports of this kind, and/or delaying distribution. Doctor Lee
253112 - has notified VA management that the report on findings and
253113 - recommendations in the report on cause of stroke symptoms is
253114 - urgent for guiding continuing work. At this time status is
253115 - unknown. Doctor Lee will ask the Chief of Surgery for an
253116 - undate on getting at least an interim report from the doctor
253117 - assigned to perform Peer Review of stroke symptoms, ref SDS K0
253118 - 4W4N, that occurred following EGD dilation procecure on 160617.
253119 - ref SDS H1 5F6F
253121 - ..
253122 - On 170404 0800 Doctor Lee said that as a result of delays
253123 - completing peer review for EGD dilation on 160617, another
253124 - doctor was assigned to do the work, and it has now been
253125 - completed. ref SDS M8 Y68M We decided Doctor Lee can submit
253126 - the report during the meeting on 170419 0900, and it can be
253127 - discussed at that time, rather than take time today for review.
253128 - ref SDS M8 EW4H
253130 - ..
253131 - On 170419 0900 Doctor Lee said he has seen the peer review
253132 - report. It does not identify anything in the procedure for
253133 - causing stroke symptoms, ref SDS M9 LN7L, that occurred after
253134 - EDG procedure on 160617. ref SDS H1 5F6F He seemed to say the
253135 - report does not incorporate nor cite findings that stroke
253136 - symptoms raise questions of anesthetic-related changes +/-
253137 - seizure, from Stanford Neuroscience dated 160802, received on
253138 - 160820 0940. ref SDS I3 JF86 This was submitted to Doctor Lee
253139 - at VAMC Sacramento on 161115 0800. ref SDS J7 NW8O
253141 - ..
253142 - Will review on 170719.
253143 -
253145 - ..
253146 - 6. Conscious sedation drugs for anesthesia will not exceed amounts
253147 - that have previously not caused neurological deficits, as
253148 - occurred on 160617 1637, ref SDS H1 5F6F, and possible mild
253149 - recurrence involving left eye deficits on 161213 0800.
253150 - ref SDS L0 R74J
253152 - ..
253153 - Consider trying Versed 4 rather than 5 today, in that adverse
253154 - effects seemd to occur after using Versed 6 on 160617. The
253155 - procedure on 160816 used Versed 4, and was successful.
253156 - Subsequent procedures have used Versed 5, with no adverse
253157 - effects, except for left eye problem after procedure on 161213
253158 - 0800. ref SDS L0 R74J
253160 - ..
253161 - We agreed that in signing the consent for the procedure today,
253162 - drugs will not be added above amounts that have previously not
253163 - caused neurological deficits (i.e., stroke symptoms). If the
253164 - procedure gets prolonged, as occurred on 160617 0800,
253165 - ref SDS H0 N16M, the patient will be allowed to drift out of
253166 - sedation in order to avoid increasing sedation drugs, and
253167 - because this patient may be biologically prone to over react to
253168 - excessive sedation drugs, reported on 161011 1330. ref SDS J3
253169 - P534 We further reviewed the record showing EGD dilation
253170 - procedure was performed entirely without sedation drugs, and
253171 - was successful on 101210 0930. ref SDS 67 PK8M
253173 - ..
253174 - Doctor Lee will closely monitor conscious sedation medications
253175 - in accordance with these understandings.
253176 -
253178 - ..
253179 - 7. Triamcinolone - less than 3 mL.
253180 -
253181 - We further discussed again limiting Triamcinolone steroid
253182 - injections to 3 mL, and in order to limit side effects of...
253183 -
253184 - Vison loss
253185 - High blood pressure
253186 - Weight gain
253187 - bloating
253189 - ..
253190 - This aligns with understandings during the meeting on 160921
253191 - 1130, ref SDS I9 TI3M, and again when meeting on for prior EGD
253192 - procedure last month on 161004 0800. ref SDS J1 VV6N
253194 - ..
253195 - What guides application of Triamcinolone?
253197 - ..
253198 - Has extreme contraction of LESV to 6 mm last week, reported on
253199 - 161122 1245, ref SDS K0 433O, resulted from reducing or
253200 - eliminating Triamcinolone?
253202 - ..
253203 - On 161130, Doctor Lee seemed to say today he has injected
253204 - Triamcinolone for the procedure 2 weeks ago on 161115, and for
253205 - all procedures this year, including last week on 161130. 161130
253206 - 1038, ref SDS K3 7M4K
253208 - ..
253209 - 170106 1200 at 1608 after EGD dilation procedure today, Doctor
253210 - Lee reported there was only 1 split in LESV tissue, so he made
253211 - only 1 injection of Triamcinalone steroid, but it was 2 mL,
253212 - which normally would be enough for 2 splits; and so may help
253213 - reduce contraction of LESV over next 5 weeks until next EGD
253214 - procedure on 170210. ref SDS L6 433O
253216 - ..
253217 - Previously, the doctor injected "quadrants", i.e., going in a circle
253218 - around LESV. Might this be considered today, if contraction drops
253219 - back below 16mm?
253221 - ..
253222 - Ask about increasing Triamcialone to increase time LESV remains
253223 - expanded, based on amount of contraction today. The balance is
253224 - maintaining expansion of Triamcinalone, without accelerating
253225 - concentration week to week.
253226 -
253228 - ..
253229 - Signed consent for the procedure, which is not visible - there is
253230 - merely a black screen to sign.
253231 -
253232 -
253233 -
253235 - ..
253236 - Swallowing Improved Vomitting Difficulties Decreased
253237 -
253238 - Follow up ref SDS N4 VV6N, ref SDS M8 VV6N.
253239 -
253240 - Reported no vomiting past 8 weeks with LESV dilated to 19 mm on 170516
253241 - 0800. ref SDS N4 433O
253243 - ..
253244 - Estimated LESV will engage today at 17 mm, since there have been no
253245 - difficulties swallowing the past 8 weeks with semi-liquid diet.
253246 - Possibly there has been no contraction, and LESV has remained at 18 MM
253247 - dilated on 170404 0800, ref SDS M8 433O; Will be disappointing if LESV
253248 - contracts to 15 mm.
253250 - ..
253251 - Requested again consideration for dilating to 19 mm, if the doctor
253252 - sees minimal ulceration, and there is minimal bleeding on dilating to
253253 - 18 mm. Doctor Lee will consider this option, which he first presented
253254 - on 170221 0800. ref SDS M2 EZ6H
253255 -
253256 -
253258 - ..
253259 - OR EGD Dilation with Application Lidocaine
253260 - EGD Dilation Procedure in OR Application Lidocaine
253261 -
253262 - Follow up ref SDS N4 7V6I, ref SDS M8 7V6I.
253264 - ..
253265 - Everything went smoothly, as always with Grace in the OR today.
253267 - ..
253268 - Grace applied conscious sedation using the catheter which she set
253269 - earlier in Preparation, per above. ref SDS 0 544G Assume
253270 - understandings were applied on sedation protocol reviewed with Doctor
253271 - Lee and agreed in signing the consent, per above. ref SDS 0 8744
253273 - ..
253274 - Raymond was technical assistant again today.
253276 - ..
253277 - The team then did the EDG/dilation procedure with Doctor Lee.
253279 - ..
253280 - Time Start EGD....... 0850
253281 - Time Out EGD......... 0906
253282 -
253284 - ..
253285 - LESV Contract 6 MM Dilation 12 MM Ulceration Resolved
253286 - Meeting Doctor Lee Present Results EGD Dilation Procedure 12 MM
253287 - Results EGD Dilation Procedure Meeting Doctor Lee Present 12 MM
253288 - Liquid Diet Continue LESV Contracted 6 MM Worst in Patient History
253289 -
253290 - Follow up ref SDS N4 5H5J, ref SDS M8 5H5J.
2533 -
2534 -
2535 - 1110
2537 - ..
253701 - Woke up from conscious sedation.
253703 - ..
253704 - After the procedure, met with Doctor Lee in the recovery room.
253706 - ..
253707 - Doctor Lee reported mixed results today.
253709 - ..
253710 - LESV contracted from 19 mm down to 16, showing improvement compared to
253711 - severe weekly contractions last year, evident from case study below.
253712 - ref SDS N4 XM3J However, contracting 3 mm was much greater than the
253713 - prior 2 cycles.
253715 - ..
253716 - Doctor Lee dilated the opening to 18 mm, and so was unable to reach 19
253717 - mm again today, as achieved previously for the first time on 170516
253718 - 0800, ref SDS N4 433O, and for the first time in 10-year patient
253719 - history. (aligns with Discharge Instructions saying Dilation 15.0 - 19
253720 - mm). Equally important, 3 splits occurred expanding LESV to 18 mm,
253721 - and so prevented reaching 19 mmtoday.
253722 -
253723 -
253724 -
2538 -
SUBJECTS
Achalasia Spreadsheet Correlate LESV Contractions PPI Triamcinalone
2603 -
260401 - ..
260402 - EGD Chart Correlate Time Dilation Triamcinalone Sedation Drugs
260403 -
260404 - Follow up ref SDS N4 XM3J, ref SDS M8 XM3J.
260405 -
260406 - Excel spreadsheet medications posted from case study exercise, diet,
260407 - vitals, medications...
260408 -
260409 - F:\05\00003\SM\CC\CHMG\FNGC\CJGK\achalasia_meds_lesv.xlsx
260411 - ..
260412 - Bena
260413 - Versed/ dryl
260414 - ** MEDICATIONS LESV DILATE Triamcin Midaz Diphenhy Fenta Lido
260415 - Months PPI FMTDN from - to olone olam dramine nyl caine
260416 - Interval Date mg mg mm mm mL mg mg mg mL
260417 - 2 170711 40 80 16 18......1.0.....5......25......250.....10.... ref SDS 0 433O
260418 - 1.50 170516 80 80 16.5 19......1.0.....5......25......250.....10.... ref SDS N4 433O
260419 - 1.50 170404 80 80 16.5 18......1.5.....5......25......200.....10.... ref SDS M8 433O
260420 - 1.50 170221 80 80 15 18......2.0.....5......25......200......5.... ref SDS M2 433O
260421 - 0.75 170106 80 80 16.5 18......2.0.....5......25......200......5.... ref SDS L6 433O
260422 - 0.25 161213 80 80 15 18......3.0.....5......25......200......5.... ref SDS L0 433O
260423 - 0.25 161206 80 80 11 16.5....1.0.....5......25......200......5.... ref SDS K6 433O
260424 - 0.25 161130 80 80 11 15......0.0.....5......25......200......5.... ref SDS K3 433O
260425 - 0.25 161122 80 80 6 12......0.0.....5......25......200......5.... ref SDS K1 433O
260426 - 1.50 161115 42 80 10 10......0.0.....5......25......200......5.... ref SDS J7 5H5J
260427 - 0.75 161004 26 80 11 15......5.0.....5......25......200......5.... ref SDS J1 HU42
260428 - *1 0.75 160909 80 0 10 15......5.0.....5......25......200......5.... ref SDS I7 HU42
260429 - 2 160816 11 40 9.5 10......5.0.....4......50......150......5.... ref SDS I1 HU42
260430 - 3 160617 10 40 9.5 15......5.0.....6......50......250......5.... ref SDS H0 HU42
260431 - *2 3 160315 15 40 9.5 15......3.0.....5......25......250......5.... ref SDS G8 HU42
260432 - 8 151204 32 20 10 15......5.0.....5......25......200......5.... ref SDS F4 HU42
260433 - *3 6 150421 41 16.5 18......3.0.....4......50......250......5.... ref SDS D4 HU42
260434 - 6 141107 37 15 18......4.0.....5......50......150......5.... ref SDS C5 E54M
260435 - 6 140509 24 16.5 18..............5......50......200......5.... ref SDS B5 P680
260436 - *4 7 131115 24 16.5 18......2.0.....4......50......200......5.... ref SDS A7 RZ45
260437 - 3 130416 38 18 18......2.0.....5......50......250......5.... ref SDS A1 Y850
260438 - 4 130110 39 15 18......3.0.....4......50......100......5.... ref SDS 96 Q333
260439 - *5 6 120925 38 15 18......4.0.....5......50......200......5.... ref SDS 88 XB51
260440 - *6 4 120322 27 16.5 18..............4......50......150......5.... ref SDS 85 516N
260441 - *7 3 111115 76 16.5 18..............4......50......200......5.... ref SDS 82 IR57
260442 - 4 110819 80 15 16.5....2.5.....5......50......200......5.... ref SDS 81 J978
260443 - 2 110429 80 13 16.5....3.5.....5..............200......5.... ref SDS 76 U23I
260444 - 2 110218 80 11 14......2.0.....4......50......150......5.... ref SDS 72 AA5O
260445 - 4 101210 40 11 14......................................5.... ref SDS 67 H347
260446 - 6 100827 4 11 15..............5......50......250......5.... ref SDS 55 JE6X
260447 - 3 100305 0 11 15..............5......50......250......5.... ref SDS 48 WR6L
260448 - - 091216 Heller Myotomy Fundoplication................. ref SDS 36 KE9U
260450 - ..
260451 - ** Dates are from case study on exercise, diet, vitals and
260452 - medication, shown on 160101, ref SDS G1 0001, and
260453 - previously on 140101. ref SDS B0 0001
260454 -
260455 - *1 On 160911 paused Pantoprazole to reduce dehydration through
260456 - frequent urination until after Half Dome, and resumed on
260457 - 160920.
260458 -
260459 - *2 On 151210 begin Omeprazole 20 mg every other day. ref SDS B0 E64G
260460 - Resumed Omeprazole 20 mg on 160323. ref SDS G1 RSXR
260462 - ..
260463 - On 150924 hospitalized hematoma debridement; begin Omeprazole
260464 - 20 mg per day. ref SDS B0 JT4N
260465 -
260466 - *3 On 150920 about 5 attacks convulsions, nausea not taking
260467 - Omeprazole - took 40 mg. ref SDS B0 656M
260468 -
260469 - *4 On 131115 Doctor Lee prescribed Omeprazole 40 mg 1 month then
260470 - 20 mg for next 5 months. ref SDS A7 ZY5K
260472 - ..
260473 - *5 On 130106, 4 days before EGD on 130110, reduced Omeprazole to
260474 - 20 mg per day, shown in case study on 120101 0900, ref SDS 84
260475 - AD5G
260476 -
260477 - *6 On 120907 Doctor Egan research found Omeprazole increases
260478 - blood pressure, sensed possible correlation patient sudden
260479 - rise in blood pressure, recommended reducing Omeprazole
260480 - to 20 mg per day.
260481 -
260482 - *7 On 11115 Doctor Lee prescribed continue PPM 80 mg; on 111201,
260483 - patient reduced dose to 20 mg on record of rising blood
260484 - pressure despite increased hiking; research indicated PPI may
260485 - elevate blood pressure, see case study 101010 0744, ref SDS 57 734L
260486 -
260487 -
260488 -
260489 -
260490 -
260492 - ..
260493 - Conscious Sedation Reduced Dose Applied for 15 Minutes
260494 -
260495 - Follow up ref SDS N4 714N, ref SDS M8 714N.
260496 -
260497 - No discussion of conscious sedation during post-procedure meeting.
260499 - ..
260500 - Assume understandings were applied on sedation protocol reviewed with
260501 - Doctor Lee and agreed in signing consent for the procedure today, per
260502 - above. ref SDS L0 8744
260504 - ..
260505 - No post procedure side effects as occurred on 161213 0800. ref SDS L0
260506 - R74J
260508 - ..
260509 - During the meeting this morning, Doctor Lee did not have time to
260510 - submit the report, per above, ref SDS 0 7W3H, on cause of stroke
260511 - symptoms following EGD on 160617 1637. ref SDS H1 5F6F This
260512 - afternoon, the doctor was again pressed for time, and so did not
260513 - submit the report, which he planned to submit today, during the prior
260514 - meeting on 170419 0900. ref SDS M9 UR8H
260515 -
260516 -
260517 -
260519 - ..
260520 - Ulceration Improved Stricture Decreased
260521 -
260522 - Follow up ref SDS N4 RZ3G, ref SDS M8 RZ3G.
260523 -
260524 - Doctor Lee presented pictures showing improved condition with reduced
260525 - ulceration of LESV, following EGD dilation procedure today...
260527 - ..
260528 - 
260530 - ..
260531 - 
260533 - ..
260534 - 
260536 - ..
260537 - This was good news.
260539 - ..
260540 - He advised that severe ulceration has continued to be completely
260541 - resolved. The prior ulceration hole adjacent to LESV opening in the
260542 - esophagus found during the procedure 5 months ago on 161115 0800,
260543 - ref SDS J7 K44N, and continuing remnants of ulceration found during
260544 - EGD procedure on 161122 1245, ref SDS K0 RZ3G, is still no longer
260545 - visible.
260547 - ..
260548 - He pointed to photographs showing slight indented cup, which has
260549 - persisted for about 5 months through multiple EGD procedures, appears
260550 - to be smoother today, indicating the indentation seems to filling in
260551 - from combination of factors that prevent ulceration.
260553 - ..
260554 - Bad news of LESV contracting to 16 mm, prevented dilating back to 19
260555 - mm today. He feels this contraction may arise from increased reflux
260556 - reaching LESV, because of reduced protection from fundoplication.
260558 - ..
260559 - Today, Doctor Lee wants to increase Pantoprazole 80 mg twice per day,
260560 - for 2 weeks, and then lower to 40 mg taken before evening meals over
260561 - next 6 weeks. Will assess affects on ulceration during next EGD in 8
260562 - weeks. If none, as today, then will continue 50% reduction for next
260563 - cycle, and assess again.
260565 - ..
260566 - Ensure - Doctor Lee prescirbed continuing liquid diet for next period
260567 - based on prior protocol reported last cycle on 170516 0800.
260568 - ref SDS N4 9H9M
260569 -
260570 - [On 170715 1047 Pharmacy listing shows Ensure ordered.
260571 - ref SDS N6 VG9N
260573 - ..
260574 - [On 170721 0429 received refill for Ensure prescription.
260575 - ref SDS N7 4S3J
260576 -
260577 -
260579 - ..
260580 - Schedule Next Procedure and Post Procedure Review
260581 -
260582 - Follow up ref SDS N4 XF6X, ref SDS M8 XF6X.
260583 -
260584 - Doctor Lee wants next EGD Dilation procedure in 8 weeks, and a week
260585 - before Half Dome to ensure no effects of sedation drugs.
260587 - ..
260588 - Gracie visited with Jessica to schedule next EGD. Jessica said the
260589 - Doctor has no openings in 8 weeks, so he will have to overbook, as
260590 - done previously.
260592 - ..
260593 - Doctor Lee then overbooked the next procedure on 170915 1200.
260595 - ..
260596 - For some reason, did not schedule follow up review for EGD on 170905,
260597 - so will do this when we meet next week to review findings and
260598 - planning today, on 170719 0900.
260600 - ..
260601 - Explain in Progress Notes correlation of triamcinalone injections with
260602 - contraction of LESV, and in relation to PPI levels.
260604 - ..
260605 - Incorporate in Progress Notes as addendum to EGD procedure on 160617,
260606 - Peer Review report on cause of stroke symptoms following the
260607 - procedure.
260609 - ..
260610 - Thanked Doctor Lee for good work today.
260611 -
260612 -
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SUBJECTS
Default Null Subject Account for Blank Record
2703 -
270401 - ..
270402 - Release of Information ROI CD Contents Received on 151224
270403 -
270404 - Follow up ref SDS N4 Q05K, ref SDS M8 Q05K.
270406 - ..
270407 - Request records on CD from ROI for this medical encounter due to
270408 - continual difficulties downloading medical records from VA website
270409 - at...
270410 -
270411 - https://www.myhealth.va.gov/mhv-portal-web/track-health
270412 -
270413 -
270420 - ..
270421 - On January 13, 2017, checked for Progress Notes for EGD on 161213, and
270422 - on 170106, and found they have not yet been posted for patient access.
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