CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10
0703 -
0703 - ..
0704 - Summary/Objective
0705 -
070501 - Follow up ref SDS 45 0000. ref SDS 43 0000.
070502 -
070503 - Checked in at 0800, planned by Roxy the day before, to VAMCSF Module 2
070504 - for pre-op meetings on patient history and fitness for surgery,
070505 - including meet with anesthesiologist. ref SDS 0 VN9S Haliandra
070506 - coordinated with Roxy to organize work plan. They did outstanding
070507 - work today. ref SDS 0 6T6K Met initially with Doctor Choukalas in ASU
070508 - to evaluate anesthesology fitness for surgery. Reviewed possibile
070509 - cumulative risks getting low dose versed. ref SDS 0 ZW6L Internet
070510 - search found no evident risk; the doctor seemed to indicate versed
070511 - would not be used for surgery in this case on Monday. ref SDS 0 KX37
070512 - Physical examination showed patient fit for surgery. ref SDS 0 PV4G
070513 - Morna submitted and explained written instructions to prepare for
070514 - surgery. ref SDS 0 K27M She took Kathy's name and cellphone for
070515 - designated driver. ref SDS 0 0C60 Morna explained shower procedure to
070516 - clean surgery site the day of surgery; she submitted cleaning
070517 - supplies. ref SDS 0 WO5F At 1100 met with Doctor Mark Berry, 2nd year
070518 - resident, and with Amer Alsoudi, 3rd year medical student. Went over
070519 - history of surgery issue, and they examined the site of surgery.
070520 - ref SDS 0 FV5M After returning home, received call from Morna
070521 - scheduling time to arrive at ASU for surgery on Monday at 1200.
070522 - ref SDS 0 6V4K
070523 -
070524 - [On 190203 1528 submitted letter to Doctor Choukalas, with
070525 - copy to Doctor Stewart confirming understandings on
070526 - anesthesia for surgery on 190204. ref SDS 46 VN9S
070527 -
070528 -
070529 -
070530 -
070531 -
070533 - ..
0706 -
0707 -
0708 - Background
0709 -
070901 - On 091030 0810 at 1406 met Doctor Stewart to evaluate performing
070902 - Heller Myotmy surgery for resolving achalasia. ref SDS 6 KE3B
070904 - ..
070905 - On 180615 1058 letter to Doctor Stewart at Gen Surgery request meeting
070906 - on 180619, at VAMCSF to review achalasia and hematoma wound issues.
070907 - ref SDS 31 VN9S
070909 - ..
070910 - On 180615 1058 at 1521 received letter from Doctor Stewart saying she
070911 - will be out of town on 180619, so call Mike and schedule time with her
070912 - on 180626 clinic. ref SDS 31 1Z4N
070914 - ..
070915 - On 180615 1058 at 1539 called Mike - he was able to schedule meeting
070916 - with Doctor Stewart on 180622 0930. ref SDS 31 517K
070918 - ..
070919 - On 180622 0930 meeting Doctor Stewart to facilitate timely treatment
070920 - achalasia to dilate LESV. ref SDS 32 TV5I Doctor Stewart scheduled
070921 - treatment with Doctor Kaltenbach in GI Clinic at VAMCSF. ref SDS 32
070922 - E66H
070924 - ..
070925 - On 180627 1300 EGD dilation performed, ref SDS 35 NU8L, by Doctor
070926 - Kaltenbach, who arrived in OR after patient sedated; Doctor Patel,
070927 - Fellow, explained after procedure that LESV contracted to 12 mm and so
070928 - Doctor Kaltenbach could only dilate to 16.5 mm, and did not apply
070929 - Triamcinalone, which has been used the past 8 years in this case.
070931 - ..
070932 - On 180625 0823 letter thanks Doctor Stewart for coordinating EGD
070933 - dilation treatment next week with Doctor Kaltenbach in GI Clinic at
070934 - VAMCSF. ref SDS 33 VN9S
070936 - ..
070937 - On 190102 1025 called VAMCSF General Surgery and asked to speak with
070938 - Mike for scheduling meeting with Doctor Stewart. Talked to Teri. She
070939 - said Mike has retired. Someone will call back on scheduling meeting
070940 - with Doctor Stewart. ref SDS 42 IG4M Sent letter to Doctor Stewart
070941 - discussing meeting to evaluate surgery to remove growing lump on back.
070942 - ref SDS 42 WY7O
070944 - ..
070945 - On 190122 1520 meeting Doctor Stewart; Sarah did initial interview,
070946 - discussed Versed should not cause cumulative effects getting sedation
070947 - every 4 weeks for EGD procedures. ref SDS 44 1N67 Doctor Stewart said
070948 - to discuss with anesthesiologist. ref SDS 44 WS9F The doctor scheduled
070949 - surgery on 190204, to remove lump on back. Sarah prepared consent for
070950 - surgery. Signed consent. ref SDS 44 QU39
070952 - ..
070953 - On 190131 1014 Roxy called and scheduled meetings tomorrow on 190201
070954 - 0800, at VAMCSF for patient history and physical to get surgery on
070955 - Monday, 190204. ref SDS 45 VN9S She also scheduled meeting with
070956 - anesthesiologist in ASU Department on 3rd floor. ref SDS 45 PQ9Q
070958 - ..
070959 - On 190202 0800 Checked in at Module 2 for pre-op meetings on patient
070960 - history and fitness for surgery.ref SDS 0 VN9S Haliandra coordinated
070961 - with Roxy to organize work plan. They did outstanding work today.
070962 - ref SDS 0 6T6K Met with Doctor Choukalas in ASU on anesthesology
070963 - fitness for surgery. Reviewed possibile cumulative risks getting low
070964 - dose versed. ref SDS 0 ZW6L Internet search found no evident risk;
070965 - doctor seemed to indicate versed would not be used for surgery in this
070966 - case. ref SDS 0 KX37 Physical showed patient fit for surgery.
070967 - ref SDS 0 PV4G Morna submitted and explained instructions to prepare
070968 - for surgery. ref SDS 0 K27M Morna explained shower procedure to clean
070969 - surgery site; she submitted cleaning supplies. ref SDS 0 WO5F At 1100
070970 - met with Doctor Mark Berry, and with Amer Alsoudi, medical student.
070971 - Went over history of surgery issue. They examined site of surgery.
070972 - ref SDS 0 FV5M After returning home, received call from Morna
070973 - scheduling time to arrive at ASU for surgery on Monday at 1200.
070974 - ref SDS 0 6V4K
070975 -
070976 -
070977 -
070978 -
070979 -
070981 - ..
0710 -
0711 -
0712 - Progress
0713 -
071301 - Pre-Op Meetings at VAMCSF Prepare Surgery Remove Lump on Back
071302 -
071303 - Prepare for surgery on Monday, 190204, have to do following tasks
071304 - today at 0800, scheduled by Roxy yesterday on 190131 1014. ref SDS 45
071305 - VN9S
071306 -
071307 - Module 2 for history and physical, may include lab.
071309 - ..
071310 - ASU - meeting with anesthesiologist
071311 -
071313 - ..
071314 - On arriving, nobody was in either of the 2 workstations at Module 2.
071316 - ..
071317 - Haliandra [not sure about spelling] came out from a back area and said
071318 - she would check me in. She asked for last name and last 4 digits of
071319 - social security number, then returned to the back area.
071321 - ..
071322 - This checkin seemed uncertain. Another lady across the aisle in
071323 - Module 1, asked if I have been checked in? Said not sure, since
071324 - Haliandra could forget to do the checkin, and might not remember
071325 - details of patient ID once she got around to doing the checkin.
071327 - ..
071328 - The lady in Module 2 checked me in.
071330 - ..
071331 - Halindra came into the waiting area and asked for last name and last 4
071332 - again. The other lady said she did the check in. Haliandra went back
071333 - to her workstation in the back area. She returned in 10 minutes and
071334 - said she cannot find in the system who is supposed to see me today.
071336 - ..
071337 - Suggested she call Roxy, who set up this meeting in a call yesterday,
071338 - reported on 190131 1014. ref SDS 45 VN9S
071340 - ..
071341 - Halindra came back about 5 minutes later and said she cannot reach
071342 - Roxy. She also tried calling Izagani, and he does not answer either.
071344 - ..
071345 - Halindra suggested we go to Izagani's office and if he is not
071346 - available we can go to the 3rd floor to visit with Roxy.
071347 -
071348 -
071349 -
071351 - ..
0714 -
0715 -
0716 - 0821
0717 -
071701 - Search for Medical Staff Perform Patient History and Physical
071702 -
071703 - We walked across the street to building 203, and went to the 2nd
071704 - floor. Knocked on Izagani's office door. Nobody answered. We went
071705 - into Med-Surg. Haliandra said Izagani has another office, so we
071706 - knocked on that door. Nobody answered.
071708 - ..
071709 - We walked back to building 200, using the 2nd floor elevated, enclosed
071710 - hallway. Took elevator to the 3rd floor surgery department. Roxy was
071711 - not there.
071712 -
071714 - ..
0718 -
0719 -
0720 - 0829
0721 -
072101 - Since we were already in the Sugery Department, we went to ASU at the
072102 - other end of the hall and around the corner from Surgery Admin. The
072103 - ASU attendant said I am scheduled to see an anesthesiologist at 0900.
072105 - ..
072106 - We took the elevator to ground floor, and walked over to Module 2.
072107 - Decided to go work in the cafeteria while Halindra figures out the
072108 - schedule for work today. Gave her cellphone number to call and advise
072109 - where to go and when to meet with someone.
072111 - ..
072112 - Just then Roxy returned Halindra's several messages.
072114 - ..
072115 - Roxy said she has left a message for a resident to do the patient
072116 - history and physical, but has not heard back yet. She suggested going
072117 - to ASU and meeting 1st with anesthesiology, then return to module 2,
072118 - and hopefully by then, a resident will be available for doing the
072119 - history and physical.
072121 - ..
072122 - Tbanked Haliandra for terrific coordination and persistence today.
072123 -
072124 -
072125 -
072126 -
072128 - ..
0722 -
0723 -
0724 - 0848
0725 -
072501 - Meeting ASU Anesthesiology for Surgery on 190204
072502 -
072503 - Went back to ASU on the 3rd floor of building 200.
072505 - ..
072506 - Checked in.
072508 - ..
072509 - Chris Choukalas, MD Anesthesiologist called the meeting.
072510 -
072511 - chris.choukala@va.gov
072513 - ..
072514 - UCSF Profile...
072515 -
072516 - https://profiles.ucsf.edu/christopher.choukalas
072518 - ..
072519 - Very interesting and helpful meeting.
072520 -
072522 - ..
072523 - Versed Possible Cumulative Effects at Low Dose Stroke Risks
072524 -
072525 - Initially, asked about cumulative effects of versed. Explained
072526 - current regimen getting EGD dilation procedures every 4 weeks, at VAMC
072527 - in Sacramento with Doctor Lee. On 180711 0900, the doctor ordered
072528 - this schedule for the next year, beginning on 180713. ref SDS 36 RE9L
072530 - ..
072531 - On 160617, EGD dilation procedure was extended to 30 minutes. This
072532 - resulted in getting versed 6 mg with 1 mg injected every 4 - 6
072533 - minutes. ref SDS 21 P341 The duraton of the procedure and the amount
072534 - of versed were both 100% greater than any prior EGD procedure going
072535 - back to 2010, when the amount of versed was typically 3 - 4 mg, and
072536 - never exceeded 5 mg. After discharge from the procedure on 160617,
072537 - began experiencing stroke symptoms of mild left side motor control and
072538 - vision deficits, reported in the record on 160617 1637. ref SDS 22
072539 - 5F6F Symptoms were treated in the ER at VAMCSF later that night on
072540 - 160617 1637 at 2229. ref SDS 22 0179 MRI was performed the next
072541 - morning on 160618 0251, reported in the record on 160617 1637.
072542 - ref SDS 22 027K
072544 - ..
072545 - Later that morning neurology examination reported MRI finding "several
072546 - areas suspicious for leptomeningeal enhancement," 160618 1348,
072547 - ref SDS 23 HQ5G, and "...enhancement compatible with a likely subacute
072548 - right SCA territory infarct." ref SDS 23 WK7K Patient was treated for
072549 - stroke until on 160802, Stanford Neuroscience reviewed the MRI and
072550 - reported in a letter to VAMCSF, received by the patient on 160820
072551 - 0940, that MRI on 160618, shows "...no true restricted diffusion..."
072552 - ref SDS 26 JZ66 Stanford further stated: "MRI does not show any acute
072553 - stroke, but does have subcortical and right cerebellar white matter
072554 - changes of uncertain age." ref SDS 26 OE7M Standford concluded: "The
072555 - diffuse leptomeningeal enhancement! increased vascularity most
072556 - prominent in a culprit right frontal region raises question of
072557 - anesthetic-related changes +/- seizure, PRES, and less likely
072558 - malignancy, autoimmune/vasculitis, or infectious changes given bland
072559 - LP, patent's stability, and lack of headache." ref SDS 26 JF86
072561 - ..
072562 - Doctor Lee's team has since limited administering versed for EGD
072563 - procedures to less than 6 mg, since it appears the patient has
072564 - hypersensitivity to versed 6+ mg, which most patients tolerate well.
072565 - There has been no recurrence of stroke symptoms with this regimen.
072567 - ..
072568 - The current question is whether there can be a cumulative effect
072569 - getting 3 - 5 mg versed every 4 weeks continually?
072571 - ..
072572 - Patient seems to have suffered cumulative effects of statin drugs. In
072573 - 2012, there was significant peripheral neruopathy in right foot and
072574 - less in left foot, when taking high dose statins, e.g, 80 mg. Statins
072575 - were reduced in 2013, to "scant" dose of Atorvastatin 10 mg with
072576 - Ezitimibe 10 mg both every other day. This has lowered LDL
072577 - cholesterol from 200+ down to 100 +/-, and there has been no
072578 - recurrence of peripheral neuropathy over the past 5 years. LDL 100
072579 - +/- presents healthy lipid profile, when combined with HDL 83,
072580 - resulting from hiking 11 - 20+ miles per day, shown by favorable CCTA
072581 - testing. Low blood pressure and heart rate are further metrics
072582 - showing improved circulatory conditions. However, last year in
072583 - October mild peripehral neruopathy recurred, indicating a very small
072584 - cumulative rise of statin side effects even at very low dosage.
072586 - ..
072587 - Mild peripheral neuropathy lasting 5 minutes hiking a quarter mile in
072588 - hikes 11 - 20 miles seems harmless, and is not debilitating in any
072589 - way.
072591 - ..
072592 - Recurrence of stroke symptoms from cumulative effects of low dose
072593 - versed, might be more serious.
072595 - ..
072596 - Chris did quick research on the computer in the office. He did not
072597 - find reporting on this issue. He was not aware of versed having a
072598 - cumulative effect given every 4 weeks.
072600 - ..
072601 - Chris further seemed to indicate that versed would not be used for the
072602 - procedure on Monday.
072603 -
072604 - [On 190203 1528 submitted letter to Doctor Choukalas, with
072605 - copy to Doctor Stewart confirming understandings on
072606 - anesthesia for surgery on 190204. ref SDS 46 VN9S
072607 -
072609 - ..
072610 - Voice Disruption Achalasia Closes LESV Saliva Builds Up to Larynx
072611 -
072612 - Chris asked about my raspy voice, saying he has similar issues
072613 - sometimes.
072615 - ..
072616 - Explained voice disruption evident in the meeting today, is caused by
072617 - achalasia from buildup of salavia on top of LESV, reaching larynx.
072619 - ..
072620 - Doctor Lee has treated achalasia starting at VA Clinic in Martinez,
072621 - beginning in July 2005, and continuing at VAMC in Sacramento, since
072622 - 2012. Doctor Stewart, who is performing the surgery tomorrow,
072623 - performed Hellar Myotomy surgery on 091216, that relieved symptoms of
072624 - achalasia. In March 2010, Doctor Lee began doing EGD dilation
072625 - procedures to compliment the prior surgery. This has worked well over
072626 - the ensuing years.
072627 -
072629 - ..
072630 - Reflux Controlled by Medications Fundoplication Relaxed LESV Ulcerated
072631 -
072632 - Chris asked about medication to control acid reflux?
072634 - ..
072635 - The original work plan was for Dor fundoplication Doctor Stewart
072636 - constructed during surgery on 091216, to prevent reflux onto LESV and
072637 - into the esophagus. This worked well for several years. OA November
072638 - 2014, fundoplication relaxed. This caused acid burn and ulceration on
072639 - bottom of LESV, which Doctor Lee calls a "stricture." The stricture
072640 - compounds the natural closing of LESV that occurs with achalasia.
072641 - Many medication protocols were tried to reduce reflux with minimal
072642 - success.
072644 - ..
072645 - On 160914, hiked Half Dome again. On the way coming down took 2
072646 - Naproxen pills to relieve feet and knee pain, using minimal water.
072647 - The pills evidently got stuck on top of LESV, though not noticed at
072648 - the time. In following days, at home food got stuck from taking
072649 - Naproxen pills without any water during hikes.
072650 -
072652 - ..
072653 - Weekly EGD Dilation Procedures Medication Changes Resolved Ulceration
072654 -
072655 - The next several EGD procedures were difficult to dilate LESV due to
072656 - severe ulceration. Use of Naproxen was ended. We experimented with
072657 - medication regimens. Doctor Lee increased frequency of procedures to
072658 - weekly, and eventually was able to resolve ulceration injuries and
072659 - restore LESV to normal dilations of 18 mm, that enable near-normal
072660 - swallowing. In July of last year, Doctor Lee prescribed EGD dilations
072661 - every 4 weeks for the year. Since about 3 months ago, the doctor has
072662 - been dilating LESV to 20 mm, which aids swallowing.
072664 - ..
072665 - Doctor Stewart has consulted with Doctor Lee at VAMC in Sacramento,
072666 - through meetings with the patient at VAMCSF, to achieve significant
072667 - recovery from achalasia. There have been ongoing discussions about
072668 - repairning fundoplication to reduce reflux onto LESV.
072669 -
072671 - ..
072672 - Medication Regimen Controls Reflux
072673 -
072674 - For past 2 years, have been taking Pantoprazole, Famotidine, Mylanta
072675 - and Calcium Carbonate (Tums), as shown in daily report of exercise,
072676 - vitals, medication and diet, for example today, in case study on
072677 - 190101 0730. ref SDS 41 3V5L Have learned to use eating practices
072678 - that aid swallowing. As a result have had no vomitting episodes for
072679 - past 2 years, where previously they occurred routinely with every
072680 - meal.
072682 - ..
072683 - In the past 6 months, have taken Naproxen on occasion for pain
072684 - management, but only 1 pill and with plenty of water.
072685 -
072687 - ..
072688 - Doctor Jothi Consulted on Voice Disruption
072698 - ..
072699 - We briefly reviewed meeting with Doctor Sumana Jothi at VA Clinic in
072700 - Martinez, on referral from Doctor Lee in GI Clinic at VAMC in
072701 - Sacramento, reported on 180924 0900, ref SDS 38 OL5O, with results
072702 - confirmed in the letter to Doctor Jothi on 181001 1948. ref SDS 39
072703 - NU8L As stated in the letter, Doctor Jothi reported using gastroscope
072704 - in some cases to repair fundoplication, as an alternate to accessing
072705 - LESV with conventional surgery.
072707 - ..
072708 - Explained Doctor Lee's theory that saliva builds up above LESV, and
072709 - eventually interferes with larynx, causing voice alteration. Drinking
072710 - carbonated beverages and sitting/standing vertical helps clear the
072711 - problem, so voice returns to normal. Similarly, eating chochlate
072712 - bar, like Mr Goodbar, seems to drag saliva through LESV, returning
072713 - voice to normal.
072714 -
072716 - ..
072717 - Physical Examination Good-to-Go Surgery on 190204
072718 -
072719 - Chris did a physical examination.
072721 - ..
072722 - Vitals showed elevated blood pressure, conflicting with normal vitals
072723 - this morning, reported in case study on 190101 0730. ref SDS 41 3V5L
072725 - ..
072726 - Elevated blood pressure and heart rate align with running 4 flights of
072727 - stairs to the 3rd floor, before arriving in ASU.
072729 - ..
072730 - He examined the mouth, asked about dentures and contacts.
072732 - ..
072733 - Chris said he or another doctor will provide anesthesiology services
072734 - for the surgery on Monday. He noted that, if another doctor does the
072735 - anestheology on Monday, the doctor will have access to his (Doctor
072736 - Choukalas') Progress Notes for patient history on sedation safety
072737 - issues discussed today.
072739 - ..
072740 - Advised that Doctor Brezinski did the anesthology for CABG surgery.
072741 - We had an interesting and helpful meeting, like today, to support his
072742 - work on the heart surgery, and in connection with the achalasia issue,
072743 - reported on 091022 0700. ref SDS 5 JF9K
072745 - ..
072746 - Chris said that Doctor Brezinsky is still working at VAMCSF.
072748 - ..
072749 - At that time on 091022, we planned to keep patient head and neck
072750 - slightly elevated to prevent backflow from the stomach through LESV
072751 - into the esophagus, in order to prevent choking. ref SDS 5 0U4O
072752 -
072754 - ..
072755 - Hiking Good Solution Maintain Physical Condition
072756 -
072757 - Chris related having hiked to the top of Mount Tamalpias recently.
072759 - ..
072760 - Explained increasing extended endurance exercise hiking and running 11
072761 - - 20+ miles per day in order to raise HDL cholesterol. Hiked Half
072762 - Dome in Yosemite last year on 180912 0545. ref SDS 37 0001 Often
072763 - arrive early for meetings at the VA, and hike down to Ocean Beach, to
072764 - JFK and through the Park to Stanyon and down to Paramount near the
072765 - Koret Gymnasium. Entire route out-and- back is 12 miles.
072767 - ..
072768 - Chris likes hiking up the long, steep hill from Ocean Beach to the VA.
072770 - ..
072771 - We will try to do a hike together sometime.
072773 - ..
072774 - We went to Surgery Pre-Op administration area. Chris introduced
072775 - Morna.
072776 -
072777 -
072779 - ..
0728 -
0729 -
0730 - 0926
0731 -
073101 - Instructions Patient Prep, Report-for-Surgery, Designated Driver
073102 -
073103 - Meeting with Morna.
073104 -
073105 - Morna submitted a document....
073106 -
073107 - ABMULATORY SURGERY UNIT
073108 - Building 200 3rd floor, room 3A-122
073109 - San Francisco VA Medical Center
073110 - 4150 Clement Street, San Francisco, CA 94121
073111 - Phone: 415 221 4810, extension 23521 or 25048
073113 - ..
073114 - Welcome to the VA! Here are instructions for the day of surgery
073115 -
073116 - PRE-OP CALL
073117 -
073118 - Your surgery/procedure is scheduled on 2019 02 04
073119 -
073120 - An ASU nurse will call you by 2PM the business day before your
073121 - procedure to provide you with the approximate time of your
073122 - surgery and at what time you should arrive at the hospital.
073124 - ..
073125 - Admission time __________ AM
073127 - ..
073128 - During the meeting, Morna said someone will call before 1400 today,
073129 - and advise what time to arrive at ASU on Monday for the surgery.
073130 -
073131 - [...below on 190201 0800 at 1254 Morna called and said to
073132 - meet in ASU next Monday, on 190204 1200. ref SDS 0 6V4K
073134 - ..
073135 - ABMULATORY SURGERY UNIT document continues...
073136 -
073137 - If you do not receive a call by 2 PM the business day before
073138 - your surgery, please call the ASU (see above).
073140 - ..
073141 - If you have any questions or need to cancel your surgery,
073142 - please call us at the ASU.
073144 - ..
073145 - RIDE PROTOCOL
073146 -
073147 - Do not drive yourself for 24 hours after your surgery or
073148 - procedure. Arrange for a responsible adult to escort you
073149 - home. If you do not have a ride, your surgery will be
073150 - rescheduled.
073152 - ..
073153 - During the meeting, Morna asked for designated driver - gave her
073154 - Kathy's name and cellphone number.
073155 -
073156 - [...below on 190201 0800 at 1254 Morna called and advised
073157 - that she also called and notified Kathy about date and time
073158 - to checkin for surgery on Monday. ref SDS 0 T15M
073160 - ..
073161 - ABMULATORY SURGERY UNIT document continues...
073162 -
073163 - PROCEDURE LOCATION
073164 -
073165 - Report to the ASU: Building 200 3rd Floor, Room 3A-122.
073166 -
073167 - Please check in with the clerks at the Window in the waiting
073168 - room.
073170 - ..
073171 - EATING AND DRINKING BEFORE SURGERY
073172 -
073173 - Please do not eat or drink anything after midnight on the day
073174 - of surgery.
073175 -
073176 - May take medications with sips of water.
073178 - ..
073179 - PREOP SHOWER
073180 -
073181 - Shower/bath and shave as always before coming to the hospital
073182 -
073183 - If you were given a scrub brush or cloth, please use as
073184 - instructed.
073186 - ..
073187 - Do not shave the site of the operation itself.
073189 - ..
073190 - Do not apply makeup or moisturizers the day of surgery.
073192 - ..
073193 - Morna submitted a plastic bag containing...
073194 -
073195 - Document saying...
073197 - ..
073198 - Chlorhexidine Scrub Before Surgery
073199 -
073200 -
073201 - 1. Open the package and use the BRUSH side to scrub your
073202 - body from the neck down.
073204 - ..
073205 - 2. Use a gentle back and forth motion, avoiding eyes,
073206 - ears, nose and mouth.
073208 - ..
073209 - Morna said don't try to wash the area of the surgery on the back,
073210 - because it is too difficult to reach. Wash neck and shoulders above
073211 - the surgery site and let soapy water drip down over the site of the
073212 - lump to be removed.
073213 -
073214 - [On 190204 1200 applied shower instructions washing surgery
073215 - site with scrub brush. ref SDS 47 FE9N
073217 - ..
073218 - Chlorhexidine Scrub Before Surgery document continues...
073219 -
073220 - 3. Rinse thoroughly with water.
073221 -
073222 - 4. If redness or itching results from use of the product,
073223 - discontinue use and call the:
073225 - ..
073226 - Telephone Advice Nurse at 1 800 733 0502 or
073228 - ..
073229 - ASU nurses at 415 221 4810 ext 23521 or 25048
073230 -
073232 - ..
073233 - Plastic bag also contains...
073234 -
073235 - Plastic bag containing a scrub brush inside plastic
073236 - packaging, with writings that say...
073237 -
073238 - BD E-Z Scrub 107
073239 - Surgical scrub brush sponge
073240 -
073241 - 4% CHG
073243 - ..
073244 - NDC 17271-107-03
073246 - ..
073247 - REF 371073
073249 - ..
073250 - LOT 8256984
073251 - EXP 2020-09
073253 - ..
073254 - Drug facts:
073256 - ..
073257 - Active ingredient
073258 - 4% Chlorhexidine gluconate w/v
073260 - ..
073261 - Purpose: antiseptic
073263 - ..
073264 - Use: preoperative cleaning of healthcare personnel
073265 - arms and hands
073267 - ..
073268 - Keep out of the reach of children
073270 - ..
073271 - Directions:
073272 -
073273 - 1. wet hands and forearms to the elbows with
073274 - warm water
073275 -
073276 - 2. Use nail cleaner and apply scrub solution from sponge
073277 - side; work up lather
073279 - ..
073280 - 3. Scrub nails cuticles and interdigital spaces
073281 - thoroughtly for 3 minutes with brush side and hands
073282 - and forearms with the sponde side.
073284 - ..
073285 - 4. Rinse with warm water. Repeat scrub for 3 more
073286 - minutes use the same sponge side only. Add water as
073287 - necessary to produce the desired level of suds.
073289 - ..
073290 - 5. Rinse hands and arms thoroughtly. Dry thoroughly.
073291 -
073293 - ..
073294 - Other Information:
073295 -
073296 - 1. avoid excessive heat 40 C (104 F)
073297 -
073298 - 2. discard after single use.
073299 -
073301 - ..
073302 - WHAT TO BRING
073303 -
073304 - Do not bring any medications with you. They will be provided
073305 - for you during your hospital stay. If you plan to use lodging
073306 - before or after surgery, bring only the medications you will
073307 - need for those days.
073309 - ..
073310 - If you are admitted to the hospital, any medications that are
073311 - brought into the facility will be sent to the pharmacy and
073312 - returned to you when discharged.
073314 - ..
073315 - Do not wear jewlery or contact lenses and remove body piercings
073317 - ..
073318 - Wear cansual, loose fitting and comfortable clothing.
073320 - ..
073321 - Leave all valuables at home, including jewlery and body
073322 - piercings.
073323 -
073325 - ..
073326 - Thanked Morna for comprehensive pre-op support.
073327 -
073328 -
073329 -
073331 - ..
0734 -
0735 -
0736 - 0938
0737 -
073701 - Continue Search for Medical Team Perform Patient History and Physical
073702 -
073703 - While on the 3rd floor, went to Surgery admininstration office to find
073704 - Roxy for work plan to perform Patient History and Physical
073705 - examination, per work plan above. ref SDS 0 JF34
073707 - ..
073708 - This is a little confusing, because Chris just did a physical, per
073709 - above. ref SDS 0 PV4G
073711 - ..
073712 - One of the attendants found Roxy working in Podiatry today.
073714 - ..
073715 - Talked to Roxy on telephone.
073717 - ..
073718 - We decided to meet in Module 2.
073719 -
073721 - ..
0738 -
0739 -
0740 - 0944
0741 -
074101 - Went to module 2 and met Roxy.
074103 - ..
074104 - She still hasn't heard from the resident, and so doesn't know where
074105 - the examination for h&p will be performed.
074106 -
074108 - ..
074109 - Cafeteria Entering Progress Record Waiting for Plan on H&P
074110 -
074111 - Decided to work in the cafeteria. Gave Roxy cellphone number.
074113 - ..
074114 - Roxy said it is great working with patients who are okay with
074115 - flexible meeting times.
074116 -
074118 - ..
0742 -
0743 -
0744 - 0952
0745 -
074501 - Went to cafatera.
074503 - ..
074504 - Began writing up the record to understand what has happend so far.
074505 -
074506 -
074508 - ..
0746 -
0747 -
0748 - 1012
0749 -
074901 - Beginning Find Medical Staff for H&P Examination
074902 -
074903 - Roxy called and said to meet her at 1030, in Module 2, and she will
074904 - take me to the location for the pre-op examination
074906 - ..
074907 - Took computer to the car.
074908 -
074910 - ..
0750 -
0751 -
0752 - 1030
0753 -
075301 - Waiting for Roxy in Module 2.
075302 -
075304 - ..
0754 -
0755 -
0756 - 1038
0757 -
075701 - Roxy arrives in Module 2.
075702 -
075703 - We walked back to building 203 across the street and up the 2nd
075704 - floor. Roxy knocked on Isagani's door again. No one answered.
075706 - ..
075707 - We went into Med-Surg, and again knocked on the 2nd office door where
075708 - Isagani sometimes workes, as Haliandra did this morning, per above.
075709 - ref SDS 0 N346
075711 - ..
075712 - Roxy asked someone if they where the residens office located.
075714 - ..
075715 - A nurse too us around the corner to an office with 4 or 5 resident
075716 - doctors working on computers and talking.
075718 - ..
075719 - We found the resident Roxy has been trying to find since starting work
075720 - with Halindra at 0800 this morning, per above. ref SDS 0 JE9Y
075722 - ..
075723 - Think her name is Jennel.
075725 - ..
075726 - Thanked Roxy for extra effort coordinating the work today. It was
075727 - fun working with someone determined to get the job done.
075728 -
075729 -
075730 -
075731 -
075733 - ..
0758 -
0759 -
0760 - 1109
0761 -
076101 - Meeting Patient History and Physical for Surgery on 190204
076102 -
076103 - Jennel (??) took us around the corner to another office in Med-Surg.
076104 - This is across the hall from the room I had for treatment of hematoma
076105 - wound on 150924 0330, ref SDS 19 LN6F, from falling on the Mist trail,
076106 - when hiking Half Dome the week before on 150916 0535. ref SDS 18 O87H
076108 - ..
076109 - Inside the office, she introduced...
076110 -
076111 - Mark Berry, MD (2-year resident)
076112 - Amer Alsoudi (3-year medical student)
076114 - ..
076115 - Apparently, Sarah cycled out of the residency program, so she is not
076116 - available to follow up her work with Doctor Stewart on ordering
076117 - surgery in this case, reported on 190122 1520. ref SDS 43 VT6N
076119 - ..
076120 - Amer reviewed patient history. He noted the questions are about the
076121 - same that Sarah asked during the meeting on Friday. The practice of
076122 - repeating questions to the patient is to test accuracy of VA
076123 - understandings entered into Progress Notes from the prior meeting,
076124 - i.e., the meeting today is a cross-check and so a good form of
076125 - Communication Metrics, similar to preparing an SDS record.
076127 - ..
076128 - Accordingly, explained history of present affliction, as previously
076129 - presented on 190122 1520. ref SDS 43 VT6N
076131 - ..
076132 - Mark and Amer examined the surgery site on the back. Removed shirt
076133 - fo this examination.
076135 - ..
076136 - Asked if they noticed a lot of scratches on the back.
076138 - ..
076139 - They said there are no scratches.
076141 - ..
076142 - Explained findings by Doctor Simpson of significant scratches on the
076143 - back, reported on 181031 1000. ref SDS 40 IN85
076145 - ..
076146 - Mark said there are a couple small moles here and there, but nothing
076147 - that looks like scratches, so certainly there are not a lot.
076149 - ..
076150 - Amer asked if patient has history of difficulty walking around the
076151 - house, going up stairs, getting in and out of a car, for example
076152 - shortness of breath, weakness, etc, that may indicate risks for
076153 - surgery common for old patients 10 years after heart surgery.
076155 - ..
076156 - Explained hiking 3,500 miles last year, including Half Dome a
076157 - mile-high on 180912 0545. ref SDS 37 0001
076159 - ..
076160 - Amer smiled and said patient seems physically fit for surgery.
076162 - ..
076163 - Mark said he will mention to Doctor Tseng the next time he sees her in
076164 - the hallway, that one of her former patients has made good recovery
076165 - following CABG heart surgery 10 years ago.
076167 - ..
076168 - Noted being very fortunate that Doctor Tseng was attending physician
076169 - for CABG performed on 091022 0700. ref SDS 5 LO3G Have been very
076170 - lucky to get medical care from terrific health professionals at
076171 - VAMCSF.
076173 - ..
076174 - Mark commented that doctors feel lucky when patients respond so well
076175 - to treatment.
076177 - ..
076178 - Wished Amer good luck finishing medical school at UCSF, and good luck
076179 - completing residency at VAMCSF.
076180 -
076181 -
076182 -
076183 -
076185 - ..
0762 -
0763 -
0764 - 1254
0765 -
076501 - Surgery Schedule Patient Report to ASU on 190204 1200
076502 -
076503 - Morna called, as planned during the meeting at VAMCSF, earlier this
076504 - morning, per above. ref SDS 0 0C40
076506 - ..
076507 - She said surgery will be Monday...
076508 -
076509 - 190204 1200
076511 - ..
076512 - Check in to ASU on 3rd floor.
076514 - ..
076515 - She has called and notified Kathy, per planning during the meeting
076516 - this morning, per above. ref SDS 0 0C60
076517 -
076518 -
076519 -
076520 -
076521 -
076522 -
076523 -
076524 -
076525 -
0766 -