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: April 17, 2018 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 Has Been Effective Past 4 Weeks
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 16 Minutes
16...Ulceration Improved Stricture Decreased
17...Schedule Next Procedure and Post Procedure Review
18...Progress Notes EGD Procedure on 180417 Received on 180625
19...Progress Notes EGD Dilation Today


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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 P4 0000. ref SDS P2 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250503 - No diffuculty swallowing this cycle with LESV dilated to 18 mm 6 weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250504 - ago on 180227. ref SDS 0 VV6N  No difficulty with digestion using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250505 - medication protocol, reviewed during meeting with Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250506 - 180124. ref SDS 0 PD5F  Signed blank consent for the procedure today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250507 - on assurance that stroke symptoms following prior EGD on 160617, with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250508 - mild recurrence on 161213, would not occur.  Doctor Lee was pressed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250509 - for time today, so deferred agenda issues to post-procedure meeting in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250510 - 3 weeks. ref SDS 0 KT9M  EGD dilation procedure went smoothly, with no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250511 - reports of difficulties. ref SDS 0 7V6I  Gastroscope in and out took                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250512 - 16 minutes, ref SDS 0 UT4N, and versed sedation medication required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250513 - only 3 ML, well below 6 ML that caused prior symptoms. ref SDS 0 CR4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250514 - Post procedure Doctor Lee reported good results with LESV contracting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250515 - to only 16.5 mm, so he was able to dilate LESV to 19 mm, achieving                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250516 - goal previously reached 6 procedures (a year) ago. ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250517 - Ulceration improved over the past 8 weeks, which enabled the doctor to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250518 - dilate LESV needed for better swallowing. ref SDS 0 RZ3G  Continued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250519 - improvement in ulceration and LESV dilation shows good response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250520 - treatment with prescribed medications. ref SDS 0 JK6N  Scheduled next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250521 - EGD dilation in 4 - 6 weeks, and consult in 3 weeks to review pending                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250522 - issues.  This will require another overbook, which the doctor will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250523 - work out with Paul tomorrow. ref SDS 0 ES4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250525 -             ..
250526 -            [On 180418 0932 Paul called from GI Clinic at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250527 -            Center in Sacraento; he will consult with Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250528 -            scheduling consult in 3 weeks, and next EGD dilation in 6 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250529 -            8 weeks. ref SDS P6 NU8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250531 -             ..
250532 -            [On 180423 1017 letter to Jessica requesting she notify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250533 -            Doctor Lee to call about scheduling meeting and next EGD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250534 -            ref SDS P7 OA3W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250536 -             ..
250537 -            [On 180425 1130 Kathy met with Jessica and at that time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250538 -            Jessica scheduled next EGD on 180605 0800, she scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250539 -            review meeting 6 weeks later on 180711, the next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250540 -            dilation was scheduled 2 days later on 180713, and review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250541 -            meeting was scheduled 6 days later on 180719.   The review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250542 -            meeting ordered by Doctor Lee for 3 weeks after recent EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250543 -            on 180417, is still not scheduled. ref SDS P8 9O6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250547 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250548 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250550 -  ..
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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2518 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251801 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251802 - GI Department VA Sacramento Medical Center Administration EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251803 - 
251804 - Follow up ref SDS P4 NU8L, ref SDS P2 NU8L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251806 - EGD treatment today, was scheduled by LaPria, during meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251807 - Doctor Lee on 180307 1045 at 1228. ref SDS P5 K44I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251809 -  ..
251810 - At that time, there was not enough time to also scheduled review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251811 - meeting. ref SDS P5 E44J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251813 -  ..
251814 - Performing EGD dilation 8 weeks after prior procedure on 180227 0800,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251815 - ref SDS P4 NU8L, represents continuing recovery from severe                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251816 - contraction LESV 6 mm, worst condition in patient history, found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251817 - during procedure on 161122, ref SDS K1 0001, and which prevented                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251818 - dilation above 12 mm. ref SDS K1 433O  The 8-week interval may have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251819 - been too long, since beginning about 2 weeks ago was feeling LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251820 - shutting down, with difficulty swallowing, reported on 171014, in case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251821 - study on 160101 0700. ref SDS G1 YRTP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251823 -  ..
251824 - Applied pre-proc requirements for NPO after midnight, from letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251825 - 101015 1547. ref SDS 59 4J9L  Last food was at......                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251827 -  ..
251828 - Drove to Sacramento yesterday afternoon.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251830 -  ..
251831 - At 0720, checked into GI Department at the customer counter..                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251832 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251833 -                         800-382-8387                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251834 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251835 -                         916 843 7000                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251837 -  ..
251838 - Kathy cell phone for designated driver...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251842 -  ..
251843 - Kathy signed the discharge form affirming she will be designated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251844 - driver, and responsible to facilitate no driving for 24 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251845 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251846 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251847 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251848 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251849 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251851 -  ..
2519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2521 - 0725                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252201 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252202 - 
252203 - Follow up ref SDS P4 EP75, ref SDS P2 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 - Rose did vitals today, prior to procedure in a small office just off                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252211 - the lobby, and not in the treatment preparation area, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252212 - 120925 0900. ref SDS 88 PT5P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252214 -  ..
252215 - She wore a surgeon's mask to protect against transmitted diseases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252216 - from patients.  Rose seemed a little wobbly today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252218 -  ..
252219 - Vitals found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252220 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252221 -            Weight.................. 179                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252222 -            BP...................... 128 59                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252223 -            HR (pulse).............. 62                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252224 -            Oxygen.................. 99                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252225 -            Temp.................... 97                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252227 -  ..
252228 - Rose asked questions on patient history to verify ready for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252229 - procedure, e.g., no allergies, and NPO after midnight to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252230 - conflicts with anesthesia; no health problems, e.g., no diabetes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252231 - alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252232 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252234 -  ..
2523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2525 - 0742                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252601 - Followed Hazel into the GI Prep area.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252603 -  ..
252604 - Ann configured on gurney and connected equipment to monitor vitals                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252605 - during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252607 -  ..
252608 - Frank set catheter IV for sedation.  He was not successful on 1st                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252609 - stick; it was pain level 6.  Veins develop adhesions (scar tissue) and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252610 - take time to heal, and prevent blood flow into the IV needle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252611 - Denise consulted.  Frank moved the needle penetration down slightly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252612 - and this 2nd stick was successful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252614 -  ..
252615 - Case study on sticks required to set catheter is reported on 110429                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252616 - 1230. ref SDS 76 UO3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252618 -  ..
252619 - Ann went through patient identification and medical profile filling                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252620 - out forms on the computer based on prior information 7 weeks ago on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252621 - 180109 0800. ref SDS P2 6Y8K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252622 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252624 -  ..
252625 - She asked about pain?  Reported level 0.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252626 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252627 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252628 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252630 -  ..
2527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2529 - 0905                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
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 P4 KT9M, ref SDS P2 KT9M.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253005 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253006 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253007 - procedure today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253009 -  ..
253010 - Noted that signature is entered on completely black screen, required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253011 - without reading online documents.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253013 -  ..
253014 - Advised that signature is based on following understandings...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253016 -  ..
253017 - Agenda Meeting Doctor Lee...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253018 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253019 -    1.  Orthopedic issues - had 3rd PRP injection treatment for both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253020 -        feet and both knees last Friday, on 180105 1630, ref SDS P0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253021 -        0001, which was reported previously to Doctor Lee during prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253022 -        EGD procedure on 180109 0800. ref SDS P2 GX4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253023 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253025 -         ..
253026 -    2.  Internist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253027 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253028 -        Trying to avoid pain medication.  About 2 hours after hikes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253029 -        legs can be very painful, especially walking downstairs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253031 -         ..
253032 -        About 4+ hours after hiking rest of body feels "bad".                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253034 -         ..
253035 -        Occasionally take hydrocodone before hiking to suppress pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253036 -        in feet.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253038 -         ..
253039 -        Took hydrocodone after 12 mile hike starting at 0400 through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253040 -        Golden Gate Park, preparing for lab at 0730 at VAMCSF.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253042 -         ..
253043 -        Doctor Tucker prescribed avoiding NSAIDs, e.g., ibuprofen,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253044 -        naproxen, because these drugs prevent production of collagen,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253045 -        stimulated by PRP treatment to regenrate ligaments and tendons,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253046 -        cartilage, reported on 170726 1600. ref SDS N7 656F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253048 -         ..
253049 -        Naproxen most effective pain relief, after hydrocodone, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253050 -        pills cause ulceration LESV.  Can Doctor Lee order liquid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253051 -        naproxen to prevent this problem?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253052 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253054 -         ..
253055 -    3.  Voice very scratchy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253056 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253057 -        Primary care provider, Lauren Rettberg wrote letter reporting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253058 -        she found patient voice difficult to follow.  She wants GI                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253059 -        doctor to investigate during examination for EGD on 180417.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253060 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253061 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253063 -         ..
253064 -    4.  Pantoprazole - effective taking 1 40 mg pill per day, beginning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253065 -        on 170615, shown in case study on 160101 0700, ref SDS G1 YS7H,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253066 -        and with Famotidine 2 40 mg pills twice per day, beginning on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253067 -        170725, shown in case study on 160101 0700, ref SDS G1 1R9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253069 -         ..
253070 -        Full medication regimen reported to Doctor Lee during meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253071 -        at VA Medical Center in Sacramento on 180124 1130. ref SDS P3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253072 -        5I5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253074 -         ..
253075 -        Assess today, toward maintaining reduced dose, or increase                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253076 -        dose on findings of ulceration LESV recurrance.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253078 -         ..
253079 -        Feet seem recovered from dehydration, previously caused by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253080 -        high dose Pantoprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253082 -         ..
253083 -        Blood pressure seems trending down after reducing Pantoprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253084 -        and increasing hiking, and further reducing Mylanta and calcium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253085 -        carbonate (Tums).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253087 -         ..
253088 -        Study on proton pump inhibitor (PPI) - Pantoprazole and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253089 -        Omeprazole - requested by Doctor Lee on 170301 1200,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253090 -        ref SDS M4 A89F, was completed on 170331 1400. 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  Vitals added to exercise and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253097 -        lipid lab report...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253098 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253099 -              F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253101 -         ..
253102 -    5.  Fundoplication failing, causing continual stricture of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253103 -        requiring frequent dilation.  Doctor planned to research this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253104 -        issue during meeting on 171115 1142. ref SDS O5 XA4F  Discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253105 -        again during meeting on 180124 1130. ref SDS P3 CT56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253107 -         ..
253108 -        Did not discuss today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253109 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253111 -         ..
253112 -    6.  Conscious Sedation with versed - asked Doctor Lee to limit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253113 -        injection of versed to 3 mg, if feasible, and in no case do not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253114 -        exceed 5 mg, in order to avoid stroke symptoms on 160617 1637,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253115 -        ref SDS H1 5F6F, following EGD earlier that day when procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253116 -        took 30 minutes, 100% longer, and so versed was increased to 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253117 -        mg, reported on 160617 0800, ref SDS H0 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253119 -  ..
253120 - Also discussed with Crispin, who performed conscious sedation drug                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253121 - injections.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253122 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253123 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253125 -  ..
253126 - Swallowing Has Been Effective Past 4 Weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253127 - 
253128 - Follow up ref SDS P4 VV6N, ref SDS P2 VV6N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253129 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253130 - Reported 1 vomiting event past 8 weeks.  Occurred 6 days ago on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253131 - 180411, shown in case study on 180101 0820. ref SDS O9 RTQR  Only                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253132 - about 10% after dinner.  Follows LESV dilated to 18 mm on 180227 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253133 - ref SDS P4 433O  This has been over 12 months since prior vomitting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253134 - 161125, shown in case study on 160101 0700. ref SDS G1 643I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253136 -  ..
253137 - Bubbles clogging LESV increased the past week.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253139 -  ..
253140 - Burping seems reduced.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253142 -  ..
253143 - No difficulty with digestion using medication protocol, reviewed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253144 - during meeting with Doctor Lee on 180124 1130. ref SDS P3 5I5H  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253145 - confirmed prior review the doctor requested on 171206 0830.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253146 - ref SDS O8 QR3L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253147 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253148 -        Famotidine............... 2 40mg pills in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253149 -        Pantoprazole............. 1 40mg pill 30 min before dinner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253150 -        Mylanta.................. 60 ml OA 2200 - 1 hour after statin pills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253151 -        Calcium Carb (Tums)...... 2 500mg pills 30 min after Mylanta                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253152 -        Famotidine............... 2 40mg pills before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253154 -  ..
253155 - Reviewed eating practice - small bites taken with liquid, and mixing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253156 - meat products with other food enables each bite to slip past small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253157 - opening of LESV until next EGD dilates again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253159 -  ..
253160 - Estimated LESV will engage today at 17 mm, since there has been no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253161 - difficulty swallowing, reported on 180108 in case study on 160101                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253162 - 0700. ref SDS G1 UVQV  Maybe less, since past week have started                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253163 - having saliva buildup (bubbles) in esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253165 -  ..
253166 - Requested again consideration for dilating to 19 mm, if the doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253167 - sees minimal ulceration, and there is minimal bleeding on dilating to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253168 - 18 mm.  Doctor Lee will consider this option, which he first presented                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253169 - on 170221 0800. ref SDS M2 EZ6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253170 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253171 -            [...below on 180417 0800 at 1120 Doctor Lee reported he was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253172 -            able to dilate LESV to 19 MM today. ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253173 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253175 -  ..
2532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2534 - 0918                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253501 - OR EGD Dilation with Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253502 - EGD Dilation Procedure in OR Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253503 - 
253504 - Follow up ref SDS P4 7V6I, ref SDS P2 7V6I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253506 -  ..
253507 - Everything went smoothly, as always with nurse Frank in the OR today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253509 -  ..
253510 - Frank applied conscious sedation using the catheter Mary set earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253511 - in Preparation, per above. ref SDS P4 544G   Understandings were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253512 - applied on sedation protocol reviewed with Doctor Lee and agreed in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253513 - signing the consent, per above. ref SDS P4 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253515 -  ..
253516 - Did not get name of technical assistant today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253518 -  ..
253519 - The team then did the EDG/dilation procedure with Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253521 -  ..
253522 - Time Start EGD....... 0929                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253523 - Time Out EGD......... 0945                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253525 -  ..
253526 - Total time...........   16 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253528 -   
253529 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253532 -  ..
253533 - LESV Contract 6 MM Dilation 12 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253534 - Meeting Doctor Lee Present Results EGD Dilation Procedure 12 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253535 - Results EGD Dilation Procedure Meeting Doctor Lee Present 12 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253536 - Liquid Diet Continue LESV Contracted 6 MM Worst in Patient History                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253537 - 
253538 - Follow up ref SDS P4 5H5J, ref SDS P2 5H5J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
2536 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2538 - 1100                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2540 -    ..
254001 - Woke up from conscious sedation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254002 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254004 -  ..
2541 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2543 - 1120                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254401 - After the procedure, met with Doctor Lee in the recovery room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254402 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254403 - Before the doctor arrived for discussion, requested copy of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254404 - handwritten report on drugs administered during procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254406 -  ..
254407 - Post Procedure Record shows 800 ML normal saline infused.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254408 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254409 -   
254411 -  ..
254412 - Post Procedure Care Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254413 - Patient received in Recovery 0950 and woke at 1050.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254414 - Blood pressure 117/67 to 149/80  Heart Rate 72 - 52                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254415 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254416 -   
254418 -  ..
254419 - Nursing Procedural Sedation & Analgesia Flow Sheet Record - Page 1 of 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254420 - Versed total.............   3 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254421 - Fentanyl total........... 200 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254422 - Benadryl.................  25 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254423 - Lidocaine................   2 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254424 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254425 -   
254426 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254428 -  ..
254429 - Doctor Lee reported good results again today.  He seemed very pleased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254430 - about top of LESV that showed severe ulceration on 160816 0800,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254431 - ref SDS I1 RZ3G, but today there is no further indentation in LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254432 - tissue.  LESV tissue has "grown" back to normal contours.  Everything                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254433 - looks smooth and nomal, shown in photographs taken with gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254434 - during the procedure...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254436 -               ..
254437 -   
254439 -               ..
254440 -   
254442 -               ..
254443 -   
254445 -  ..
254446 - LESV contracted from 18 mm down to 16.5 mm, showing continuing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254447 - improvement compared to severe weekly contractions last year, evident                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254448 - from case study below. ref SDS 0 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254450 -  ..
254451 - Doctor Lee dilated the opening to 19 mm, as discussed during the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254452 - meeting this morning, above. ref SDS 0 H14J  Great to finally repeat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254453 - prior dilation to 19 mm, after 6 previous procedures when 19 mm was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254454 - achieved a year ago on 170516 0800. ref SDS N4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254456 -  ..
254457 - This was done in 2 increments, yet still required only 3 mg of versed,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254458 - also discussed this morning, per above. ref SDS 0 639M  Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254459 - started with 15 mm balloon.  It did not begin to dilate LESV until                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254460 - 16.5 mm.  He then inflated the balloon gradually dilating LESV to 18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254461 - mm again, where he observed minor splits in LESV that did not cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254462 - bleeding.  So he inserted the next size ballon and was able to dilate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254463 - LESV to 19 mm, causing more severe splits with bleeding, and so                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254464 - stopped dilation procedure.  The record today, continues improvement                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254465 - from prior procedure, when the doctor could only dilate to 18 mm, 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254466 - weeks ago on 180227 0800. ref SDS P4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254468 -  ..
254469 - The doctor indicated the current medication and eating regimens, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254470 - above, ref SDS 0 PD5F, have resolved prior achalasia difficulties,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254471 - i.e., work today demonstrated strong response to treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254472 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254473 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254474 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254475 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 P4 XM3J, ref SDS P2 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     180417   40  160     16.5   19......1.0.....3......25......250.....10.... ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260418 -          1.50  180227   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260419 -          1.25  180109   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260420 -          1     171128   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS O7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260421 -          2     171031   40  160     15.5   18......1.0.....4......25......250.....10.... ref SDS O3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260422 -          1.53  170905   80   80     15     18......1.0.....3......25......250.....10.... ref SDS N9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260423 -          1.53  170516   80   80     16.5   19......1.0.....5......25......250.....10.... ref SDS N4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260424 -          1.53  170404   80   80     16.5   18......1.5.....5......25......200.....10.... ref SDS M8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260425 -          1.53  170221   80   80     15     18......2.0.....5......25......200......5.... ref SDS M2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260426 -          0.80  170106   80   80     16.5   18......2.0.....5......25......200......5.... ref SDS L6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260427 -          0.23  161213   80   80     15     18......3.0.....5......25......200......5.... ref SDS L0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260428 -          0.20  161206   80   80     11     16.5....1.0.....5......25......200......5.... ref SDS K6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260429 -          0.27  161130   80   80     11     15......0.0.....5......25......200......5.... ref SDS K3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260430 -          0.23  161122   80   80      6     12......0.0.....5......25......200......5.... ref SDS K1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260431 -          1.40  161115   42   80     10     10......0.0.....5......25......200......5.... ref SDS J7 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260432 -          0.83  161004   26   80     11     15......5.0.....5......25......200......5.... ref SDS J1 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260433 -     *1   0.80  160909   80    0     10     15......5.0.....5......25......200......5.... ref SDS I7 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260434 -          2     160816   11   40      9.5   10......5.0.....4......50......150......5.... ref SDS I1 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260435 -          3     160617   10   40      9.5   15......5.0.....6......50......250......5.... ref SDS H0 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260436 -     *2   3     160315   15   40      9.5   15......3.0.....5......25......250......5.... ref SDS G8 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260437 -          8     151204   32   20     10     15......5.0.....5......25......200......5.... ref SDS F4 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260438 -     *3   6     150421   41          16.5   18......3.0.....4......50......250......5.... ref SDS D4 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260439 -          6     141107   37          15     18......4.0.....5......50......150......5.... ref SDS C5 E54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260440 -          6     140509   24          16.5   18..............5......50......200......5.... ref SDS B5 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260441 -     *4   7     131115   24          16.5   18......2.0.....4......50......200......5.... ref SDS A7 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260442 -          3     130416   38          18     18......2.0.....5......50......250......5.... ref SDS A1 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260443 -          4     130110   39          15     18......3.0.....4......50......100......5.... ref SDS 96 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260444 -     *5   6     120925   38          15     18......4.0.....5......50......200......5.... ref SDS 88 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260445 -     *6   4     120322   27          16.5   18..............4......50......150......5.... ref SDS 85 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260446 -     *7   3     111115   76          16.5   18..............4......50......200......5.... ref SDS 82 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260447 -          4     110819   80          15     16.5....2.5.....5......50......200......5.... ref SDS 81 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260448 -          2     110429   80          13     16.5....3.5.....5..............200......5.... ref SDS 76 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260449 -          2     110218   80          11     14......2.0.....4......50......150......5.... ref SDS 72 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260450 -          4     101210   40          11     14......................................5.... ref SDS 67 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260451 -          6     100827    4          11     15..............5......50......250......5.... ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260452 -          3     100305    0          11     15..............5......50......250......5.... ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260453 -          -     091216               Heller Myotomy Fundoplication................. ref SDS 36 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260455 -         ..
260456 -     ** Dates are from case study on exercise, diet, vitals and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260457 -        medication, shown on 160101, ref SDS G1 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260458 -        previously on 140101. ref SDS B0 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260459 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260460 -     *1 On 160911 paused Pantoprazole to reduce dehydration through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260461 -        frequent urination until after Half Dome, and resumed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260462 -        160920.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260463 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260464 -     *2 On 151210 begin Omeprazole 20 mg every other day. ref SDS B0 E64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260465 -        Resumed Omeprazole 20 mg on 160323. ref SDS G1 RSXR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260467 -         ..
260468 -        On 150924 hospitalized hematoma debridement; begin Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260469 -        20 mg per day. ref SDS B0 JT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260470 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260471 -     *3 On 150920 about 5 attacks convulsions, nausea not taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260472 -        Omeprazole - took 40 mg. ref SDS B0 656M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260473 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260474 -     *4 On 131115 Doctor Lee prescribed Omeprazole 40 mg 1 month then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260475 -        20 mg for next 5 months. ref SDS A7 ZY5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260477 -         ..
260478 -     *5 On 130106, 4 days before EGD on 130110, reduced Omeprazole to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260479 -        20 mg per day, shown in case study on 120101 0900, ref SDS 84                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260480 -        AD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260481 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260482 -     *6 On 120907 Doctor Egan research found Omeprazole increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260483 -        blood pressure, sensed possible correlation patient sudden                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260484 -        rise in blood pressure, recommended reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260485 -        to 20 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260486 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260487 -     *7 On 11115 Doctor Lee prescribed continue PPM 80 mg; on 111201,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260488 -        patient reduced dose to 20 mg on record of rising blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260489 -        pressure despite increased hiking; research indicated PPI may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260490 -        elevate blood pressure, see case study 101010 0744, ref SDS 57 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260491 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260492 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260493 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260494 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260495 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260497 -  ..
260498 - Conscious Sedation Reduced Dose Applied for 16 Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260499 - 
260500 - Follow up ref SDS P4 714N, ref SDS P2 714N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260502 - Nursing Procedural Sedation & Analgesia Flow Sheet Record Page 1 shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260503 - versed 3 ML.  Since procedure only took 16 minutes, the doctor was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260504 - able to minimize exposure to versed, which previously caused stroke                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260505 - symptoms with 6 ml, as occurred on 160617 0800. ref SDS H0 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260507 -  ..
260508 - No post procedure side effects as occurred on 161213 0800. ref SDS L0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260509 - R74J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260511 -  ..
260512 - Seem very sleepy though even hours after the procedure using just 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260513 - ml versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260514 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260516 -  ..
260517 - Ulceration Improved Stricture Decreased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260518 - 
260519 - Follow up ref SDS P4 RZ3G, ref SDS P2 RZ3G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260521 - Doctor Lee presented pictures showing improved condition with reduced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260522 - ulceration of LESV, following EGD dilation procedure today, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260523 - ref SDS 0 GD5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260525 -  ..
260526 - He advised that severe ulceration has continued to be completely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260527 - resolved.  The prior ulceration hole adjacent to LESV opening in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260528 - esophagus found during the procedure on 161115 0800, ref SDS J7 K44N,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260529 - and continuing remnants of ulceration found during EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260530 - 161122 1245, ref SDS K0 RZ3G, is still no longer visible.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260532 -  ..
260533 - As a result, the doctor was able to dilate LESV from 16.5 - 19mm,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260534 - shown in the table above. ref SDS 0 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260536 -  ..
260537 - Today, Doctor Lee wants to continue Pantoprazole 40 mg and Famotidine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260538 - 160 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260539 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260540 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260542 -  ..
260543 - Schedule Next Procedure and Post Procedure Review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260544 - 
260545 - Follow up ref SDS P4 XF6X, ref SDS P2 XF6X.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260547 - Asked about his daughter attending college?  The doctor said his                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260548 - daughter received acceptance offers from 3 schools in the UC system,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260549 - and 1 from a college in Chichago.  Finally coached him to say the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260550 - college in Chicago is Loyola University.  His daughter wants to attend                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260551 - there.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260553 -  ..
260554 - Doctor Lee wants next EGD Dilation procedure in 4 - 6 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260556 -  ..
260557 - He said this will have to be an overbook.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260559 -  ..
260560 - Doctor Lee further ordered consult in 3 weeks, which will also have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260561 - to be an overbook.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260563 -  ..
260564 - Doctor Lee said another patient is waiting for treatmet, so he does                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260565 - not have time to check his schedule to determine overbook dates.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260566 - asked Paul to work on this tomorrow, when he calls to check on patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260567 - response to treatment performed today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260569 -  ..
260570 - Thanked Doctor Lee for good work today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260572 -  ..
260573 - Paul submitted a pink sheet with Doctor Lee's prescription for next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260574 - procedure and consult.  He said to give the pink sheet to the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260575 - receptionist at the front desk.  She will schedule dates available in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260576 - the computer.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260578 -  ..
260579 - Tomorrow Paul will call to check on patient response to treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260580 - During that call Paul will work on implementing the doctor's order for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260581 - follow up EGD in 6 - 8 weeks and consult in 3 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260582 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260583 -            [On 180418 0932 Paul called from GI Clinic at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260584 -            Center in Sacraento; he will consult with Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260585 -            scheduling consult in 3 weeks, and next EGD dilation in 6 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260586 -            8 weeks. ref SDS P6 NU8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260588 -             ..
260589 -            [On 180423 1017 letter to Jessica requesting she notify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260590 -            Doctor Lee to call about scheduling meeting and next EGD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260591 -            ref SDS P7 OA3W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260593 -             ..
260594 -            [On 180425 1130 Kathy met with Jessica and at that time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260595 -            Jessica scheduled next EGD on 180605 0800, she scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260596 -            review meeting 6 weeks later on 180711, the next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260597 -            dilation was scheduled 2 days later on 180713, and review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260598 -            meeting was scheduled 6 days later on 180719.   The review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260599 -            meeting ordered by Doctor Lee for 3 weeks after recent EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260600 -            on 180417, is still not scheduled. ref SDS P8 9O6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260601 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260602 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260603 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260604 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260606 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260609 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2703 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270401 -  ..
270402 - Progress Notes EGD Procedure on 180417 Received on 180625                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270403 - 
270404 - Follow up ref SDS P4 Q05K, ref SDS P2 Q05K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270406 -  ..
270407 - On 180625, received this file downloaded from VA Internet server.  It                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270408 - was signed by the doctor on 180527, and includes numerous reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270409 - flowing from EGD Dilation procedure on 180417.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270410 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270411 -              https://www.myhealth.va.gov/mhv-portal-web                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270412 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270419 -  ..
270420 - Progress Notes stored in...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270421 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270422 -              F:\05\00003\SM\CC\AGMJ\20180417-080000\mhv_WELCH_20180625_1120.txt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270423 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270425 -  ..
270426 - Progress Notes EGD Dilation Today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270427 - 
270428 - Follow up ref SDS P4 9N5G, ref SDS P2 9N5G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270429 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270430 -    1.  Date/Time:               17 Apr 2018 @ 0800                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270431 -        Note Title:              EGD 60111                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270432 -        Location:                No CA Healthcare Sys-Martinez                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270433 -        Signed By:               LEE,RANDALL E                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270434 -        Co-signed By:            LEE,RANDALL E                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270435 -        Date/Time Signed:        17 Apr 2018 @ 1018                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270436 -        -------------------------------------------------------------------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270438 -         ..
270439 -        LOCAL TITLE: EGD 60111                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270440 -        STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270441 -        DATE OF NOTE: APR 17, 2018@08:00     ENTRY DATE: APR 17, 2018@10:17:53                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270442 -        AUTHOR: LEE,RANDALL E        EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270443 -        URGENCY:                            STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270444 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270445 -           *** EGD 60111 Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270447 -         ..
270448 -        EGD 1953322:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270449 -        GE junction stricture at 39cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270450 -        no active ulceration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270451 -        TTS balloon dilated 16.5 to 19mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270452 -        triamcinolone acetate 40mg/ml injected 0.5ml x3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270453 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270454 -        /es/ Randall E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270455 -        Staff Physician, Gastroenterology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270456 -        Signed: 04/17/2018 10:18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270457 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270458 -        04/17/2018 ADDENDUM                      STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270460 -         ..
270461 -    2.  PATIENT NAME:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270465 -         ..
270466 -        DATE OF BIRTH: 03/01/1945                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270468 -         ..
270469 -    3.  NAME OF PROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270470 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270471 -        1.  Esophagogastroduodenoscopy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270472 -        2.  TTS balloon dilation of esophageal stricture.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270473 -        3.  Endoscopic triamcinolone injection.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270475 -         ..
270476 -        ATTENDING PHYSICIAN:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270477 -        Randall E. Lee, M.D.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270479 -         ..
270480 -    4.  INDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270481 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270482 -        Rodney Charles Welch is a 73-year-old man with underlying history of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270483 -        achalasia.  He had laparoscopic myotomy and fundoplication at San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270484 -        Francisco VA in 2009.  This relieved his achalasia associated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270485 -        dysphagia, but he subsequently developed esophageal reflux strictures                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270486 -        and has required repeated endoscopic dilations.  His most recent EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270487 -        and dilation was February 2018 at which time his stricture was dilated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270488 -        from 16.5-18 mm.  Triamcinolone acetate was injected at a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270489 -        concentration of 20 mg/mL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270491 -         ..
270492 -        In the interim over the past week has noted some recurrence of saliva                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270493 -        building up in the esophagus and only 1 episode of food impaction                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270494 -        requiring vomiting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270496 -         ..
270497 -    5.  CONSENT:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270498 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270499 -        The risks, benefits, and alternatives to this procedure including but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270500 -        not limited to the risks of bleeding and bowel perforation were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270501 -        explained to the patient.  The patient understood and provided written                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270502 -        informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270504 -         ..
270505 -    6.  INTRAVENOUS MEDICATION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270507 -        1.  Diphenhydramine 25 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270508 -        2.  Fentanyl 200 mcg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270509 -        3.  Midazolam 3 mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270511 -         ..
270512 -    7.  PROCEDURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270513 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270514 -        In the Sacramento VA GI Endoscopy Unit, the patient was placed in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270515 -        left lateral decubitus position.  Oxygen at 2 liters per minute by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270516 -        nasal cannula was administered.  Continuous oximetric and hemodynamic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270517 -        monitoring was initiated.  Intravenous sedation was administered in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270518 -        divided doses.  A bite block was placed in the patient's mouth and an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270519 -        Olympus GIF-HQ190 videogastroscope was advanced under direct vision to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270520 -        the esophagus.  The GE junction was noted at 39 cm and was easily                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270521 -        traversed by the gastroscope without resistance or trauma.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270522 -        gastroscope was advanced into the third portion of the duodenum.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270523 -        Retroflexed views of the incisura, fundus, and cardia were performed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270524 -        A TTS balloon was positioned across the lower esophageal sphincter and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270525 -        the balloon was inflated sequentially from 15-16.5-18 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270526 -        Circumferential contact was noted at 15 mm.  No visible trauma was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270527 -        noted until expansion to 16.5 mm.  The balloon was deflated, removed,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270528 -        and replaced with a second larger balloon.  This was inflated from 18-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270529 -        19 mm.  The balloon was deflated, removed, and 3 areas of mucosal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270530 -        damage were injected with submucosal injections of triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270531 -        acetate at a concentration of 40 mg/mL.  Injections were made at 0.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270532 -        mL aliquots.  Total volume was 1.5 mL.  The stomach was decompressed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270533 -        and the gastroscope removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270535 -         ..
270536 -    8.  COMPLICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270538 -        None immediate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270540 -         ..
270541 -    9.  FINDINGS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270543 -        1.  Dilated proximal, mid, and distal esophageal body without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270544 -            peristaltic waves.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270546 -        2.  Smooth esophageal mucosa without significant defects.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270548 -             ..
270549 -        3.  Previously identified mucosal defect at site of prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270550 -            esophageal ulcers at about 35 cm from the incisors.  These                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270551 -            continued to remain fully epithelialized without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270552 -            surrounding erythema, edema or active ulceration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270554 -             ..
270555 -        4.  GE junction stricture at 30 cm without ulceration, erythema                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270556 -            or mass effect.  Initial diameter continues to be 16.5 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270557 -            as sized by the balloon.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270559 -             ..
270560 -        5.  Gastric fundus appearance consistent with prior history of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270561 -            fundoplication with recurrent small hiatal hernia and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270562 -            occasional prolapse of gastric mucosa into the hiatal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270563 -            hernia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270565 -             ..
270566 -        6.  Normal gastric mucosa in the fundus and body.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270568 -             ..
270569 -        7.  Patchy gastric antral erythema without erosion, ulceration or mass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270570 -            effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270572 -             ..
270573 -        8.  Normal pylorus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270575 -             ..
270576 -        9.  Normal duodenum to D3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270578 -         ..
270579 -   10.  IMPRESSION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270580 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270581 -        Distal esophageal stricture dilated from approximately 16.5 to 19 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270582 -        No evidence of acute inflammation.  No evidence of malignancy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270584 -         ..
270585 -   11.  RECOMMENDATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270586 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270587 -        1.  Continue with current medical therapy with famotidine and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270588 -            pantoprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270589 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270590 -        2.  Repeat EGD and dilation in approximately 8 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270592 -             ..
270593 -        3.  Continue periodic washout of esophageal body with carbonated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270594 -            beverages to avoid candida esophagitis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270595 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270597 -         ..
270598 -   12.  DISPOSITION:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270599 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270600 -        1.  The patient was observed in the Recovery Room then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270601 -            discharged to home with a companion.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270602 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270603 -        2.  I reviewed the endoscopic findings and recommendations with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270604 -            the patient prior to discharge.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270607 -         ..
270608 -        TIME START: 0929 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270609 -        TIME END:   0945 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270611 -         ..
270612 -        Total time:   16 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270614 -         ..
270615 -        D:  04/17/2018                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270616 -        T:  04/18/2018                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270617 -        Job number:  1953322                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270618 -        LRM/CMTS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270619 -        $end:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270620 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270621 -        /es/ Randall E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270622 -        Staff Physician, Gastroenterology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270623 -        Signed: 05/27/2018 22:03                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270624 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270625 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270626 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270627 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270628 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270629 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2707 -