CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2503 -    ..
2504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
2505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250501 - Follow up ref SDS V8 0000. ref SDS V7 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250503 - No diffuculty swallowing this cycle with LESV dilated to 20 mm 8 weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250504 - ago on 191112. ref SDS 0 VV6N  Reported no further aspiration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250505 - problems, waking up choking, after Doctor Lee ordered increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250506 - Mylanta on 190618. ref SDS 0 N27F  Reviewed pending issues, including                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250507 - frequent urination taking Pantoprazole every day, causing dehydration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250508 - now seems stabalized. ref SDS 0 UI5N  Signed blank consent for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250509 - procedure today, on assurance that stroke symptoms following prior EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250510 - on 160617, with mild recurrence on 161213, would not occur by holding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250511 - versed below 6, and aiming for 3 mg. ref SDS 0 639M  EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250512 - procedure was successful with no complications. ref SDS 0 HE9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250513 - Gastroscope in and out took 13 minutes.  Gastroscope in and out took                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250514 - 12 minutes. ref SDS 0 UT4N  Versed sedation medication required only 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250515 - mg, well below 6 mg that caused prior stroke symptoms. ref SDS 0 CR4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250516 - Post procedure Doctor Lee reported good results with LESV contracting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250517 - to only 19 mm, so he was able to dilate LESV back to 20 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250518 - ref SDS 0 GD5K  Ulceration significantly resolved over past 8 weeks,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250519 - which enabled the doctor to dilate LESV needed for better swallowing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250520 - ref SDS 0 RZ3G  Continued improvement in ulceration and LESV dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250521 - shows good response to treatment with prescribed medications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250522 - ref SDS 0 JK6N  Scheduled next EGD dilation in 8 weeks on 200310                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250523 - 0830.  Jessica schedule procedures through May of Next year.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250524 - ref SDS 0 XF6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250525 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250529 -  ..
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 66 BE7K - dilated LESV again from 11 to 14                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251079 - mm. ref SDS 66 BF6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251081 -  ..
251082 - On 101216 1021 letter commends medical team for excellent work, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251083 - confirms schedule next EGD on 110218 0730. ref SDS 68 K35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251085 -  ..
251086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251087 - anesthesia with Fentanyl. ref SDS 71 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 71 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 75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 75 U23I, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251097 - triamcinolone injections were continued. ref SDS 75 SS5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251099 -  ..
251100 - On 110607 1414 visited GI Department, ref SDS 77 HC5H, and Charlene                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251101 - reported a computer mistakes requires scheduling next EGD dilation on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251102 - 110819 0830. ref SDS 77 N642  Requested meeting with Doctor Lee to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251103 - review pending action items. ref SDS 77 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 80 J978, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251110 - triamcinolone injections were continued. ref SDS 80 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 81 IR57; for some reason triamcinolone injections to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251116 - resist contraction of LESV was not performed. ref SDS 81 IS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251118 -  ..
251119 - On 111201 0928 seems to be 10% increase in blood pressure the past                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251120 - month, ref SDS 82 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 84 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 84 UI9H  LESV dilated from 16.5 - 18 mm. ref SDS 84                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251133 - 516N  Triamcinolone injections to resist contraction of LESV was not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251134 - performed. ref SDS 84 5179                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251136 -  ..
251137 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251138 - business unit; reported patient history. ref SDS 87 RG9K  Scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251139 - EGD and dilation procedure for 1300; returned and performed procedure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251140 - ref SDS 87 TB4J; dilated from 15 mm to 18 mm. ref SDS 87 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251141 - Swallowing and vomitting problems increased after omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251142 - triamcinolone steriod injections to resist contraction of LESV after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251143 - dilation, ref SDS 87 TZ4M; therefore, injections were resumed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251144 - complement dilation to enable and maintain effective swallowing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251145 - ref SDS 87 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 95 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251152 -  ..
251153 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251154 - remained at 18 MM, ref SDS A0 CO5N, same as dialated 4 months earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251155 - on 130110 0900. ref SDS 95 Q333  Report CT test on 130117, shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251156 - esophagus fully recovered from severe distortions caused by achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251157 - 8 years earlier. ref SDS A0 MT6F  Doctor Lee injected steriod again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251158 - maintain swallowing. ref SDS A0 F38G  Prescribed reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251159 - to 1 pill per day. ref SDS A0 R74M  Scheduled next EDG dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251160 - months, instead of 3. ref SDS A0 6P6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251162 -  ..
251163 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251164 - to 18 mm. ref SDS A6 CO5N  Triamcinolone steriod injected again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251165 - maintain improved swallowing. ref SDS A6 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 A6 R74M  Biopsies taken. ref SDS A6 3N8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251169 -  ..
251170 - On 131121 1604 ordered refill of Omeprazole to aid digestion.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251171 - is 1 refill remaining. ref SDS A7 YS4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251173 -  ..
251174 - On 131205 1443 received order for Omeprazole prescription placed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251175 - 131121. ref SDS A8 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251177 -  ..
251178 - On 140318 1043 received letter cancelling meeting scheduled for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251179 - EGD/Dilation procedure on 140425 1000, ref SDS B1 935L; a second                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251180 - letter scheduled prodedure on 140509 0900. ref SDS B1 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 B2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251185 - 4P5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251187 -  ..
251188 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251189 - center in Sacramento, Mather. ref SDS B4 K37G  Pre-op preperation went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251190 - well - IV setup on first stick. ref SDS B4 EP75  Doctor ordered refills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251191 - for Omeprazole. ref SDS B4 AW5O  Doctor patient partnership continues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251192 - to progress with doctor reading up on patient history to be prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251193 - for effective meeting. ref SDS B4 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 B4 0N6I  Reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251196 - swallowing and vomitting problems reduced past 6 months with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251197 - triamcinolone steriod injections to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251198 - ref SDS B4 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 B4 5H5J, scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251201 - next EGD dilation in 6 months since this worked well the past 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251202 - with triamcinolone steriod injections. ref SDS B4 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 B4 I167  Progress notes report small tearing of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251206 - LESV during dilation procedure. ref SDS B4 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251208 -  ..
251209 - On 140718 1017 planning for notifying VA to update current fill date                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251210 - for Omeprazole. ref SDS B8 U88L  Kathy visited VA in Sacramento, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251211 - requested changing refill date for Omeprazole to 140718. ref SDS B8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
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 B8 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 C0 W83K, based on history rising vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251220 - swallowing problems, shown in patient history case study on 120101,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251221 - beginning 140712. ref SDS 83 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 C1 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 C2 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 C3 K37G  Submit record showing normal swallowing occurs longer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251239 - with triamcinolone steriod injection to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251240 - ref SDS C3 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 C3 3U66  Notified results of Half Dome hike.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251243 - ref SDS C3 3U6Y                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251245 -  ..
251246 - On 141107 0800 EGD dilation procedure - setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251247 - sedation required 3 sticks. ref SDS C4 5W5I  Meeting Doctor Lee guided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251248 - by agenda facilitated collaboration through doctor patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251249 - partnership. ref SDS C4 VV6N  Doctor explained increased difficulty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251250 - swallowing due to experiment omitting triamcinalone steriod injection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251251 - on prior procedure, ref SDS C4 4U8I, shown by LESV contracting back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251252 - from 15 mm. ref SDS C4 T55I  Progress Notes report finding ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251253 - and hiatal hernia. ref SDS C4 MG6N  Photographs seem to show                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251254 - significantly different condition of fundoplication from a year                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251255 - earlier. ref SDS C4 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 D0 0M6I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251261 - Lee advised that increased orange juice consumption aids digestion,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251262 - and presents no health risks. ref SDS D0 YF5M  Scheduled next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251263 - dilation procedure on 150421 1300. ref SDS D0 PS4O  Fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251264 - failure increases acid burn that caused ulceration with hiatal hernia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251265 - with increased recurrance achalasia. ref SDS D0 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 D0 JQ5J  Doctor Lee completed Progress Notes for EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251269 - on 141107. ref SDS D0 PS53  Doctor Lee will recommend Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251270 - order CT test to evaluate recurrance achalasia due to failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251271 - fundoplication. ref SDS D0 TH5M  This test can include coronary CTA to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251272 - evaluate regression atherosclerosis. ref SDS D0 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 D2 0M6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251278 -  ..
251279 - On 150421 Met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251280 - (Mather). ref SDS D3 K37G  No difficulties setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251281 - sedation. ref SDS D3 5W5I  Reported pain level 2 right knee MCL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251282 - ref SDS D3 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 D3 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 D3 P55L, and shown by EGD dilation LESV from 16.5 mm back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251288 - 18 mm. ref SDS D3 HU42  Progress Notes report findings of hiatal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251289 - hernia. ref SDS D3 QD6O  Impression today that ulceration has subsided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251290 - to mere errosions seems promising. ref SDS D3 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 D5 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 D7 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 D8 3E4I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251309 - Stewart explained redo Dor Fundoplication required for "repairing"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251310 - original surgery, presents high risk of collateral damage. ref SDS D8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
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 D8 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 E1 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 E2 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 E3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
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 E3 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 E5 5G8T  As a result, Pharmacy VA Medical Center San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251350 - entered new prescription for (PPI) Omeprazole 20 mg. ref SDS E5 FK66                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251352 -  ..
251353 - On 150925 0336 VA scheduled next meeting for EGD dilation on 151204                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251354 - 0800. ref SDS E5 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 E6 NV5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251362 -  ..
251363 - On 151012 1151 VA Internet Pharmacy lists updated Omeprazole 20 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251364 - prescription. ref SDS D4 0C5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251366 -  ..
251367 - On 151204 0800 met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251368 - (Mather); initial administration went well. ref SDS F3 GD4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251369 - Preparation for the procedure was professional; no difficulties                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251370 - setting IV for conscious sedation today. ref SDS F3 544G  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251371 - reported not receiving letter with agenda for the meeting today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251372 - submitted on 151201. ref SDS F3 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 F3 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 F3 G53K  Performing EGD dilation procedure went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251380 - smoothly, with no difficulties. ref SDS F3 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 F3 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 F6 J56O  Doctor prescribed adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251392 - Famotidine an H2 blocker taken once a day to compliment Omeprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251393 - ref SDS F6 YL3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251395 -  ..
251396 - On 160325 0900 Diffuculty swallowing this cycle began about 1 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251397 - after prior EGD dilation on 151204. ref SDS G7 P55L  Reported using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251398 - baking soda to relieve reflux that prevents ulceration LESV; this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251399 - reduced Omeprazole in order to avoid dehydration. ref SDS G7 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 G7 PXXY  EGD dilation procedure went smoothly, with no reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251404 - of difficulties. ref SDS G7 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 G7 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 K3 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 K6 FS5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251419 -  ..
251420 - On 180417 0800 at 1120 Doctor Lee reported he was able to dilate LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251421 - to 19 MM, the most ever. ref SDS P8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251423 -  ..
251424 - On 180425 1130 Kathy met with Jessica and at that time Jessica                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251425 - scheduled next EGD on 180605 0800, she scheduled review meeting 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251426 - weeks later on 180711, the next EGD dilation was scheduled 2 days                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251427 - later on 180713, and review meeting was scheduled 6 days later on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251428 - 180719.   The review meeting ordered by Doctor Lee for 3 weeks after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251429 - recent EGD on 180417, is still not scheduled. ref SDS Q1 9O6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251431 -  ..
251432 - On 180924 0900 meeting with Doctor Summana Jothi at VA Clinic in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251433 - Martinez, determined larynx has slight opening, not enough to cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251434 - occasinoal pronounced scratchy voice.  Reported caused by saliva                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251435 - becoming backed up, because cannot go through LESV ref SDS R8 OL5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251436 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251437 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251438 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251439 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251440 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251442 -  ..
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 V8 NU8L, ref SDS V7 NU8L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251806 - EGD treatment with Doctor Lee today, was scheduled by the doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251807 - yesterday on 200109 1411. ref SDS W6 4P7M  Previously, he called on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251808 - 200103 0700 at 1948 and paused EGD previously scheduled on 200107                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251809 - 0830, due to concern about recent cardiology care that led to patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251810 - taking Apixanab blood thinner, and Metoprolol that slows heart rate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251811 - ref SDS W3 CR6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251813 -  ..
251814 - Currently, Doctor Lee has been doing EGD procedures every 8 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251815 - Schedule was updated by Jessica extending procedures to May of this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251816 - year, reported on 190813 0730. ref SDS V4 W44N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251818 -  ..
251819 - Applied pre-proc requirements for NPO after midnight, from letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251820 - 101015 1547. ref SDS 58 4J9L  Last food was at......                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251821 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251822 -                         202009 1910                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251824 -  ..
251825 - Drove to Sacramento from Concord on Thursday, and stayed at Kathy's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251826 - house about 3 miles from VAMC Sacramento.  Yesterday, was at VAMCSF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251827 - for MRI radiology studies of feet and knees to evaluate recovery from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251828 - metatarsalgia and osteoarthritis, reported on 200109 0610, ref SDS W5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251829 - 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251830 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251831 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251833 -  ..
2519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2521 - 0755                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252201 - Arrived at VAMC Sacramento.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252203 -  ..
252204 - Shonta did check-in to GI Department at the customer counter.  She was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252205 - as usual enthusiastic and helpful.  Sonja had not come into the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252206 - office.  Shonta said she will come it about 0930.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252208 -  ..
252209 - Connie did vitals.  Rosie was working in another Department today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252211 -  ..
252212 - Connie commented favorably on the team receiving flowers and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252213 - cookies/candi treat for holidays, ordered for everyone on 191218 1253.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252214 - ref SDS V9 9O8F  Connie said she tooke the vase for the flowers home,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252215 - because she liked the design on the glass.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252217 -  ..
252218 - Vitals were taken today, and found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252219 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252220 -            Weight.................. 188                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252221 -            BP...................... 161 77                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252222 -            HR (pulse).............. 46                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252223 -            Oxygen.................. 100                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252224 -            Temp.................... 96.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252225 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252227 -  ..
252228 - Kathy cell phone for designated driver...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252232 -  ..
252233 - Kathy signed the discharge form affirming she will be designated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252234 - driver, and responsible to facilitate no driving for 24 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252236 -  ..
252237 - Was held in waiting room for 45 minutes before Mimi called me for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252238 - preparation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252239 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252240 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252241 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252242 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252244 -  ..
2523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2525 - 0850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252601 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252602 - 
252603 - Follow up ref SDS V8 EP75, ref SDS V7 EP75.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252604 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252605 - No objections nor concerns today, as occurred previously on 161115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252606 - 0800, ref SDS J8 WA5I, and again on 161130 1038. ref SDS K4 EP75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252608 -  ..
252609 - Did not see Jennifer to say hello today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252611 -  ..
252612 - Did not see Clair today, to say hello.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252614 -  ..
252615 - In the GI Clinic, Mimi directed me to a gurney.  She helped with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252616 - patient gown and setup on the gurney.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252618 -  ..
252619 - Hazel came later and entered patient history in the computer.  Most                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252620 - information entered today, for patient identification and medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252621 - history is the same.  Hazel entered recent changes:  patinet diagnosed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252622 - with atrial fibrillation following treadmill stress test on 200103                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252623 - 0700. ref SDS W3 2J4H  Patient now taking Apixaban blood thinner and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252624 - Metoprolol to slow heart rate, also reported on 200103 0700.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252625 - ref SDS W3 1X30  Apixaban was stopped 2 days ago on 200108, shown in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252626 - case study on 200101 0702. ref SDS W2 416H  Also paused Metoprolol                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252627 - this morning, ref SDS W2 B83O, IAW letter to Doctor Simpson submitted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252628 - last night, reported record on 200109 2121. ref SDS W7 WG9R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252630 -  ..
252631 - She asked about pain?  Reported level 0.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252633 -  ..
252634 - Lara set catheter IV for sedation.  She asked for best location to get                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252635 - a good vein.  Explained inner right elbow right side vein used last                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252636 - month with success on 1st stick.  Did 10 pushups with feet on gurney                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252637 - to improve blood flow.  Lara chose site on left side of right inner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252638 - arm about 2" below elbow.  She was successful on 1st stick.  This was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252639 - pain level 7.  Veins develop adhesions (scar tissue) that take time to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252640 - heal, and prevent blood flow into the IV needle.  This morning ran hot                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252641 - water on right forearm in the shower to dilate veins, which helped                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252642 - with pushups to get blood flow on 1 stick today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252644 -  ..
252645 - Case study on sticks required to set catheter is reported on 110429                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252646 - 1230. ref SDS 76 UO3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252648 -  ..
252649 - Hazel is nurse in the room today.  Mimi set blood pressure cuff and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252650 - EKG probes.  Hazel said EKG is reporting normal sinuz heart rythm this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252651 - morning.  It aligns with findings during EKG for treadmill stress test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252652 - on 200103 0700, ref SDS W3 J97F; and, with EKG prior to meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252653 - Doctor Simpson on 200108 1130. ref SDS W4 NA8J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252654 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252655 -            [...below on 200110 0830 at 1007 during procedure and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252656 -            through recovery while asleep, EKG recorded normal sinus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252657 -            heart rhythm. ref SDS 0 5C5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252667 -  ..
252668 - Gracie said she did not get the letter for Doctor Lee sent to her and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252669 - Danis on 191229 1243. ref SDS W0 4R7J  She thinks Danis got it and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252670 - submitted it to Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252672 -  ..
252673 - Many of the nurses came and said hello - gave Danis a hug.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252675 -  ..
252676 - Danis said she gave to Doctor Lee the letter on delaying EGD that was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252677 - scheduled for 200107, and which was submitted Jessica, Danis and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252678 - Gracie on 191229 1243. ref SDS W0 4R7J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252679 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252680 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252681 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252682 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252684 -  ..
2527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2529 - 1005                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253001 - New procedure was applied today.  Three months ago was wheeled into OR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253002 - before meeting with Doctor Lee to review issues and sign consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253003 - Today, at 0813 still in the preparation area.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253004 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253005 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253006 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253008 -  ..
2531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2533 - 1007                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253401 - Meeting Doctor Lee and Consent for Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253402 - 
253403 - Follow up ref SDS V8 GG6G, ref SDS V7 GG6G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253404 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253405 - Doctor Lee asked questions on patient history to verify ready for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253406 - procedure, e.g., no allergies, and NPO after midnight to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253407 - conflicts with anesthesia; no health problems, e.g., no diabetes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253408 - alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253410 -  ..
253411 - Doctor Lee asked about medication protocol?  Reported protocol he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253412 - prescribed after EGD on 190416 1000, ref SDS T7 JK6N, modified                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253413 - recently adding Apixaban and Metoprolol to treat paroxysml atrial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253414 - afibrillation, reported on 200103 0700. ref SDS W3 VT9J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253416 -  ..
253417 - This morning he confirmed the following prescription...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253418 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253419 -        Famotidine............... 2 40mg pills in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253420 -        Apixaban................. 1 05 mg pill in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253421 -        Metoprolol............... 1 25 mg pill in morning taken with PPI and food                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253422 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253423 -        Pantoprazole............. 1 40mg pill 30 min before dinner every day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253424 -        Mylanta.................. 40 ml OA 2200 - 1 hour after statins                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253425 -        Calcium Carb (Tums)...... 2 500mg pills 30 min after Mylanta                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253426 -        Famotidine............... 2 40mg pills before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253427 -        Apixaban................. 1 05 mg pill before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253429 -         ..
253430 -        Hiking paused until after cardiac catheterzation (angiogram)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253431 -        Glucosamine Chondroitin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253432 -        Oxycodone - sometimes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253433 -        Gabapentin - sometimes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253434 -        Nitroglycerin  (prescribed, but not likely to be taken)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253435 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253436 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253438 -  ..
253439 - Swallowing Has Been Effective Past 8 Weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253440 - 
253441 - Follow up ref SDS V8 VV6N, ref SDS V7 VV6N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253442 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253443 - Achalasia conditions were reported in a letter to GI Clinic on 191229                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253444 - 1243. ref SDS W0 4S99   Earlier this morning, Danis indicated she                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253445 - gave this letter to Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253447 -  ..
253448 - Reported 0 vomiting event past 8 weeks since prior EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253449 - 191112 0830. ref SDS V8 VV6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253451 -  ..
253452 - Eating regimen is shown in case study of daily diet, medication,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253453 - exercise and vitals, reported on 190101 0730. ref SDS S7 QJ5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253455 -  ..
253456 - Reviewed eating practice - small bites taken with liquid, and mixing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253457 - meat products with other food enables each bite to slip past small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253458 - opening of LESV until next EGD dilates again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253460 -  ..
253461 - Doctor Lee glanced through case study on 190101 showing exercise,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253462 - diet, medication and vitals.  He feels record on typical diet and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253463 - eating for example on 191118, aligns with requirments for effective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253464 - swallowing under achalasia, ref SDS S7 VQUY; and on 191221.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253465 - ref SDS S7 QVPV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253467 -  ..
253468 - Bubbles clogging LESV seems increased this cycle, especially past few                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253469 - weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253471 -  ..
253472 - Burping seems reduced.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253473 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253474 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253475 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253477 -  ..
253478 - Digestion Deficit Woke Up Choking Aspirated Reflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253479 - 
253480 - Follow up ref SDS V8 N27F, ref SDS V7 N27F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253481 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253482 - No aspiration issues this past cycle, since Doctor Lee ordered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253483 - increased Mylanta on 190618 0730. ref SDS U5 8468                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253484 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253485 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253486 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253488 -  ..
2535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2536 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2537 - 0847                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2538 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253801 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253802 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253803 - 
253804 - Follow up ref SDS V8 KT9M, ref SDS V7 KT9M.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253806 - Doctor Lee presented a digital tablet and requested signature to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253807 - consent for the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253809 -  ..
253810 - Noted that signature is entered on completely black screen, required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253811 - without reading online documents.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253813 -  ..
253814 - Advised that signature is based on following understandings...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253815 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253817 -         ..
253818 -    1.  Frequent urination taking Pantaprazole everyday seems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253819 -        stabalized over the past treatment cycle, at rate that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253820 -        minimizes dehydration, shown on 200101 0701. ref SDS W1 PVTP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253821 -        Occasionally, there will be nights getting up 4 - 6 times,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253822 -        e.g., on 191113 and 191113, ref SDS W1 J99F; however this is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253823 -        not persistent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253825 -         ..
253826 -    2.  Voice scratchy about the same following examination and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253827 -        recommendations by Doctor Lee during prior EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253828 -        190917 0730. ref SDS V7 HE9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253830 -         ..
253831 -        Voice worse past few weeks, even when concentrating on washing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253832 -        throat with carbonated beverage after each bite of food during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253833 -        meals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253835 -         ..
253836 -        Voice overall better after recent increase dilating LESV to 20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253837 -        mm has improved swallowing, compared to prior practice dilating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253838 -        to only 18 mm.  This has also improved voice function.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253840 -  ..
253841 - Asked Gracie about my voice today.  She said voice seems little                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253842 - scratchy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253844 -  ..
253845 - Doctor Lee concurred voice worse this morning than it has been in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253846 - the past.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253847 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253848 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253850 -         ..
253851 -    3.  Fundoplication failing, causing continual stricture of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253852 -        requiring frequent dilation.  Doctor planned to research this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253853 -        issue during meeting on 171115 1142. ref SDS O7 XA4F  Discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253854 -        again during meeting on 180124 1130. ref SDS P5 CT56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253856 -         ..
253857 -        On 180627 1300 Doctor Patel seemed to say GI Clinic at VAMCSF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253858 -        has investigated viability of gastroscope fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253859 -        procedures.  He seemed to further advise that the clinic has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253860 -        referred patients for gastroscope full fundoplication, but not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253861 -        to repair fundoplication. ref SDS Q9 JX9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253863 -         ..
253864 -        We reviewed the record in this case that Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253865 -        performed Dor fundoplication on on 091216, as shown Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253866 -        Notes received on 100928 0706. ref SDS 56 VK8F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253868 -         ..
253869 -        At tht time on 180627 1300 asked Doctor Patel to review with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253870 -        the GI team prospects to repair Dor Fundoplication in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253871 -        reduced reflux that continually causes stricture that closes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253872 -        down LESV, requiring repeated EGD dilations on close intervals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253873 -        ref SDS Q9 HP4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253875 -         ..
253876 -        Discuss with Samantha Southi developing proposal for using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253877 -        gastroscope to reposition Dor fundoplication for enhanced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253878 -        reflux control.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253880 -  ..
253881 - Did not discuss today, because seem to be managing reflux well enough                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253882 - to minimize formation of stricutre, so that swallowing is not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253883 - impaired, thus avoiding vomiting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253884 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253885 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253887 -         ..
253888 -    4.  Hiatal Hernia - can this subside or otherwise improve over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253889 -        time with any action by patient, similar to ulceration of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253890 -        recovering by ending naproxen, and adding carbonated beverage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253891 -        to washout esophagus during meals?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253893 -         ..
253894 -        What drives worsening of hiatal hernia?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253896 -  ..
253897 - Did not discuss this today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253898 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253899 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253901 -         ..
253902 -    5.  Dilation 19 - 20 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253904 -         ..
253905 -        Assess today, toward maintaining reduced medication dose, or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253906 -        increase dose on findings of ulceration LESV recurrance.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253908 -  ..
253909 - Today, Doctor Lee dilated LESV from 19/20 to 20 mm, reported in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253910 - Progress Notes shown below. ref SDS V8 X95J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253911 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253912 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253914 -         ..
253915 -    6.  Conscious Sedation with versed - asked Doctor Lee to limit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253916 -        injection of versed to 3 mg, if feasible, and in no case do not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253917 -        exceed 5 mg, in order to avoid stroke symptoms on 160617 1637,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253918 -        ref SDS H0 5F6F, following EGD earlier that day when procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253919 -        took 30 minutes, 100% longer, and so versed was increased to 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253920 -        mg, reported on 160617 0800, ref SDS G9 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253922 -  ..
253923 - This was discussed with Doctor Lee, and with Hazel, who will be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253924 - administering drugs, and so this briefing was helpful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253925 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253926 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253927 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253928 -    7.  Barium Swallow Test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253930 -  ..
253931 - After the procedure today, Doctor Lee plans to order barium swallow                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253932 - test.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253933 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253934 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253935 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253937 -  ..
2540 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2541 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2542 - 1007                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254301 - OR EGD Dilation with Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254302 - EGD Dilation Procedure in OR Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254303 - 
254304 - Follow up ref SDS V8 HE9I, ref SDS V7 HE9I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254305 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254306 - Wheeled into procedure room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254308 -  ..
254309 - Hazel was nurse for the procedure.  She connected sensors to monitor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254310 - vitals.  She connected IV to saline drip, ready to apply conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254311 - sedation drugs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254313 -  ..
254314 - Everything went smoothly in the OR today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254316 -  ..
254317 - Hazel squirted lidocaine in the mouth, and said to gargle for 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254318 - seconds.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254320 -  ..
254321 - Hazel applied versed for conscious sedation using the catheter, which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254322 - Lara set earlier in Preparation, per above. ref SDS 0 JA4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254323 - Understandings were applied on sedation protocol reviewed with Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254324 - Lee and agreed in signing the consent, per above. ref SDS 0 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254326 -  ..
254327 - Nathaniel Parker was the technician.  He remembered my name from prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254328 - procedures.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254330 -  ..
254331 - The team then did the EDG/dilation procedure with Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254333 -  ..
254334 - Gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254335 - Start Time........... 1026                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254336 - Procedure Stop....... 1038                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254338 -  ..
254339 - Total time for procedure...... 12 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254341 -  ..
254342 - Nursing Procedural Sedation & Analgesia Flow Sheet Record - Page 1 of 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254343 - Versed total................   3 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254344 - Fentanyl total.............. 150 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254345 - Benadryl....................  50 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254346 - Lidocaine...................   5 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254347 - IV Fluids normal saline.....   ? ML  NSIV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254348 - Triamcinalone...............   0 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254350 -  ..
254351 - During procedure while asleep...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254353 -  ..
254354 - Blood pressure 157/77 to 114/67  Heart Rate 46 - 56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254355 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254356 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254357 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254359 -  ..
254360 - EKG reported normal sinus heart rhythm throught the procedure...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254361 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254362 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254364 -  ..
254365 - This aligns with initial EKG readings during prep, above, ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254366 - XU4J, and with previous EKG reports meeting with Doctor Simpson in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254367 - Cardiology at VMCSF on 200108 1130, ref SDS W4 NA8J; and, previously                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254368 - during treadmill stress test on 200103 0700. ref SDS W3 J97F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254369 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254370 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254371 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254373 -  ..
254374 - LESV Contract 0 MM Dilation 20 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254375 - Meeting Doctor Lee EGD Dilation 20 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254376 - Ulceration Resolved Meeting Doctor Lee EGD Dilation 20 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254377 - 
254378 - Follow up ref SDS V8 5H5J, ref SDS V7 5H5J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254379 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254381 -  ..
2544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2545 - 1124                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254601 - Woke in recovery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254603 -  ..
254604 - Post Procedure Care Record...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254606 -  ..
254607 - Blood pressure 106/64 to 131/73  Heart Rate 48 - 56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254609 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254611 -  ..
254612 - While waiting for Doctor Lee to arrive after a procedure, talked to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254613 - Rachael.  She was the sedation nurse for the prior EDG on 191112 0830.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254614 - ref SDS V8 HE9I  Today, she mentioned hiking in Yosemite, including                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254615 - Clouds Rest.  She did not mention Half Dome.  Showed her pictures                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254616 - hiking Half Dome on 180912 0545. ref SDS R7 0001  We may try to hike                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254617 - together, if logistics can be worked out.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254618 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254619 -            [On 200117 1257 letter to Rachael on maybe doing Half Dome                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254620 -            and/or hiking in Sacramento. ref SDS W8 P45I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254622 -             ..
254623 -            [On 200310 0830 Rachael was nurse in the OR again, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254624 -            mentioned she has HDL 105; her mom has HDL 170; Rachael                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254625 -            discussed hiking again, but did not mention receiving this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254626 -            letter. ref SDS W9 QL6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254628 -  ..
254629 - Doctor Lee arrived.  He reported good results again today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254631 -  ..
254632 - LESV contracted only 1 mm from 20 back to 19 mm, showing continuing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254633 - improvement compared to severe weekly contractions, evident from case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254634 - study below. ref SDS V4 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254636 -  ..
254637 - Doctor Lee explained dilating the baloon from 19 mm to 20 mm.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254638 - was slight bleeding, but no actual breaks in LESV tissue.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254640 -  ..
254641 - Versed was limited today, to 3 ml, as discussed during the meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254642 - before the procedure, per above. ref SDS 0 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254644 -  ..
254645 - The doctor indicated current medication and eating regimens, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254646 - above, ref SDS V8 FV8H, should continue to maintain recovery from prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254647 - achalasia difficulties, i.e., work today demonstrated strong response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254648 - to treatment recovering from esophageal ulceration, including omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254649 - Triamcinalone.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254650 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254651 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254652 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254653 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254654 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2547 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 V8 XM3J, ref SDS V7 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     200110   40  160     19     20......0.0.....3......50......150.....10.... ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260418 -          2     191112   40  160     19     20......0.0.....3......50......150.....10.... ref SDS V8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260419 -          1     190917   40  160     19     20......0.0.....3......50......150.....10.... ref SDS V7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260420 -          1     190813   40  160     19     20......0.0.....3......50......150.....10.... ref SDS V4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260421 -          1     190709   40  160     20     20......0.0.....3......50......150.....10.... ref SDS V0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260422 -          1     190618   40  160     19     20......0.0.....3......50......150.....10.... ref SDS U5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260423 -          1     190521   40  160     18     20......0.0.....3......50......200.....10.... ref SDS U1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260424 -          1     190416   40  160     18     20....100.0.....3......50......200.....10.... ref SDS T7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260425 -          1     190319   40  160     19     20......0.0.....3......50......150.....10.... ref SDS T5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260426 -          1     190215   40  160     19     20......0.0.....3......50......150.....10.... ref SDS T1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260427 -          1     190118   40  160     18     20......0.0.....3......50......150.....10.... ref SDS S5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260428 -          1     181218   40  160     18     20......0.0.....4......50......150.....10.... ref SDS S5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260429 -          1     181127   40  160     18     20......0.0.....3......25......250.....10.... ref SDS S4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260430 -          1     181030   40  160     18     20......0.0.....3......25......250.....10.... ref SDS S2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260431 -          1     181002   40  160     18     20......0.0.....3......25......250.....10.... ref SDS S1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260432 -          1     180904   40  160     16.5   19......0.0.....3......25......250.....10.... ref SDS R5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260433 -          1     180814   40  160     16     19......0.0.....3......25......250.....10.... ref SDS R3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260434 -          0.5   180713   40  160     16.5   18......0.0.....3......25......250.....10.... ref SDS R0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260435 -          2.5   180627   40  160     12     16.5....0.0.....3......25......250.....10.... ref SDS Q8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260436 -          2     180417   40  160     16.5   19......1.0.....3......25......250.....10.... ref SDS P8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260437 -          1.50  180227   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260438 -          1.25  180109   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260439 -          1     171128   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS O9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260440 -          2     171031   40  160     15.5   18......1.0.....4......25......250.....10.... ref SDS O5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260441 -          1.53  170905   80   80     15     18......1.0.....3......25......250.....10.... ref SDS O1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260442 -          1.53  170516   80   80     16.5   19......1.0.....5......25......250.....10.... ref SDS N6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260443 -          1.53  170404   80   80     16.5   18......1.5.....5......25......200.....10.... ref SDS N0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260444 -          1.53  170221   80   80     15     18......2.0.....5......25......200......5.... ref SDS M3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260445 -          0.80  170106   80   80     16.5   18......2.0.....5......25......200......5.... ref SDS L7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260446 -          0.23  161213   80   80     15     18......3.0.....5......25......200......5.... ref SDS L1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260447 -          0.20  161206   80   80     11     16.5....1.0.....5......25......200......5.... ref SDS K7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260448 -          0.27  161130   80   80     11     15......0.0.....5......25......200......5.... ref SDS K4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260449 -          0.23  161122   80   80      6     12......0.0.....5......25......200......5.... ref SDS K2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260450 -          1.40  161115   42   80     10     10......0.0.....5......25......200......5.... ref SDS J8 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260451 -          0.83  161004   26   80     11     15......5.0.....5......25......200......5.... ref SDS J2 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260452 -     *1   0.80  160909   80    0     10     15......5.0.....5......25......200......5.... ref SDS I8 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260453 -          2     160816   11   40      9.5   10......5.0.....4......50......150......5.... ref SDS I2 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260454 -          3     160617   10   40      9.5   15......5.0.....6......50......250......5.... ref SDS G9 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260455 -     *2   3     160315   15   40      9.5   15......3.0.....5......25......250......5.... ref SDS G7 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260456 -          8     151204   32   20     10     15......5.0.....5......25......200......5.... ref SDS F3 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260457 -     *3   6     150421   41          16.5   18......3.0.....4......50......250......5.... ref SDS D3 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260458 -          6     141107   37          15     18......4.0.....5......50......150......5.... ref SDS C4 E54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260459 -          6     140509   24          16.5   18..............5......50......200......5.... ref SDS B4 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260460 -     *4   7     131115   24          16.5   18......2.0.....4......50......200......5.... ref SDS A6 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260461 -          3     130416   38          18     18......2.0.....5......50......250......5.... ref SDS A0 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260462 -          4     130110   39          15     18......3.0.....4......50......100......5.... ref SDS 95 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260463 -     *5   6     120925   38          15     18......4.0.....5......50......200......5.... ref SDS 87 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260464 -     *6   4     120322   27          16.5   18..............4......50......150......5.... ref SDS 84 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260465 -     *7   3     111115   76          16.5   18..............4......50......200......5.... ref SDS 81 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260466 -          4     110819   80          15     16.5....2.5.....5......50......200......5.... ref SDS 80 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260467 -          2     110429   80          13     16.5....3.5.....5..............200......5.... ref SDS 75 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260468 -          2     110218   80          11     14......2.0.....4......50......150......5.... ref SDS 71 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260469 -          4     101210   40          11     14......................................5.... ref SDS 66 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260470 -          6     100827    4          11     15..............5......50......250......5.... ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260471 -          3     100305    0          11     15..............5......50......250......5.... ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260472 -          -     091216               Heller Myotomy Fundoplication................. ref SDS 36 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260474 -         ..
260475 -     ** Dates are from case study on exercise, diet, vitals and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260476 -        medication, shown on 160101, ref SDS G0 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260477 -        previously on 140101. ref SDS A9 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260478 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260479 -     *1 On 160911 paused Pantoprazole to reduce dehydration through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260480 -        frequent urination until after Half Dome, and resumed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260481 -        160920.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260482 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260483 -     *2 On 151210 begin Omeprazole 20 mg every other day. ref SDS A9 E64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260484 -        Resumed Omeprazole 20 mg on 160323. ref SDS G0 RSXR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260486 -         ..
260487 -        On 150924 hospitalized hematoma debridement; begin Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260488 -        20 mg per day. ref SDS A9 JT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260489 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260490 -     *3 On 150920 about 5 attacks convulsions, nausea not taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260491 -        Omeprazole - took 40 mg. ref SDS A9 656M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260492 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260493 -     *4 On 131115 Doctor Lee prescribed Omeprazole 40 mg 1 month then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260494 -        20 mg for next 5 months. ref SDS A6 ZY5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260496 -         ..
260497 -     *5 On 130106, 4 days before EGD on 130110, reduced Omeprazole to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260498 -        20 mg per day, shown in case study on 120101 0900, ref SDS 83                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260499 -        AD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260500 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260501 -     *6 On 120907 Doctor Egan research found Omeprazole increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260502 -        blood pressure, sensed possible correlation patient sudden                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260503 -        rise in blood pressure, recommended reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260504 -        to 20 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260506 -     *7 On 11115 Doctor Lee prescribed continue PPM 80 mg; on 111201,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260507 -        patient reduced dose to 20 mg on record of rising blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260508 -        pressure despite increased hiking; research indicated PPI may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260509 -        elevate blood pressure, see case study 101010 0744, ref SDS 57 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260510 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260511 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260513 -  ..
260514 - Conscious Sedation Reduced Dose Applied for 11 Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260515 - 
260516 - Follow up ref SDS V8 714N, ref SDS V7 714N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260517 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260518 - Nursing Procedural Sedation & Analgesia Flow Sheet Record Page 1 shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260519 - versed 3 ML.  Since procedure only took 11 minutes, ref SDS V8 Q65I,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260520 - the doctor was able to minimize exposure to versed, which previously                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260521 - caused stroke symptoms with 6 ml, as occurred on 160617 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260522 - ref SDS G9 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260524 -               ..
260525 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260527 -  ..
260528 - No post procedure side effects as occurred previously on 161213 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260529 - ref SDS L1 R74J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260531 -  ..
260532 - Seem sleepy though even hours after the procedure using 3 ml versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260536 -  ..
260537 - Ulceration on Esophagus Above LESV Significantly Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260538 - 
260539 - Follow up ref SDS V8 RZ3G, ref SDS V7 RZ3G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260540 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260541 - Doctor Lee reported this morning that EGD procedure found that both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260542 - ulcerations on the side of esophagus above LESV continue to be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260543 - completely resolved, reported following prior EGD on 190917 0730.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260544 - ref SDS V7 RZ3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260546 -  ..
260547 - As a result, he omitted Triamcinalone again today, and maintained                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260548 - medication regimen taking Pantoprozole everyday - see case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260549 - above. ref SDS V8 YR4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260551 -  ..
260552 - Doctor Lee did not have time to present pictures showing improved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260553 - condition with reduced ulceration of LESV, following EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260554 - procedure today, per above. ref SDS V8 GD5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260556 -  ..
260557 - Pictures from procedure were later received on 191209, and are at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260558 - bottom of the file...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260559 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260560 -              F:\05\00003\SM\CC\AGMJ\20191112-083000\WELCH12092019.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260562 -  ..
260563 - Decided to continue pentoprazole everyday before dinner for next 8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260564 - weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260565 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260566 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260568 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260570 -  ..
260571 - Schedule Next Procedure and Post Procedure Review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260572 - 
260573 - Follow up ref SDS V8 XF6X, ref SDS V7 XF6X.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260574 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260575 - Next procedure is scheduled on 200310 0730, scheduled by Jessica in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260576 - the meeting on 190416 0800. ref SDS T6 DS7O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260578 -  ..
260579 - Since LESV seems to have contracted back to 19 mm during this 2 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260580 - cycle, Doctor Lee decided to skip the next scheduled procedure, and to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260581 - perform next procedure in 2 months on 2020 03 10.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260583 -  ..
260584 - Jessica scheduled procedures through May 2020.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260585 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260586 -        Mar 10 2020   0730   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260587 -        May 05 2020   0830   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260588 -        Jul 07 2020   0830   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260589 -        Sep 08 2020   0830   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260590 -        Nov 03 2020   0830   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260591 -        Jan 05 2020   0830   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260592 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260593 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260594 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260595 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260596 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260597 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260598 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260599 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260600 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2703 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270401 -  ..
270402 - Progress Notes Release of Information ROI CD Contents Received on 190316                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270403 - 
270404 - Follow up ref SDS V8 Q05K, ref SDS V7 Q05K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270406 -  ..
270407 - Request records on CD from ROI for this medical encounter due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270408 - continual difficulties downloading medical records from VA website                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270409 - at...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270410 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270411 -              https://www.myhealth.va.gov/mhv-portal-web/track-health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270412 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270419 -  ..
270420 - On 200124 Kathy went to ROI at Sacramento VA Mather Field, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270421 - received from Tracy CD with progress notes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270423 -  ..
270424 - Stored Progess Notes for procedure on 190813 at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270425 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270426 -              F:\05\00003\SM\CC\AGMJ\20200110-083000\WELCH01242020.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270428 -  ..
270429 - This file includes photographs taken during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270431 -         ..
270432 -    1.  LOCAL TITLE: EGD Procedure Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270433 -        STANDARD TITLE: GASTROENTEROLOGY DIAGNOSTIC STUDY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270434 -        DATE OF NOTE: JAN 10, 2020@10:57:05 ENTRY DATE: JAN 10, 2020@10:57:05                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270435 -        AUTHOR: CLINICAL,DEVICE PRO  EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270436 -        URGENCY:           STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270437 -        *** EGD Procedure Report Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270438 -        ** DOCUMENT IN VISTA IMAGING **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270439 -        SEE FULL REPORT IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270440 -        SIGNATURE NOT REQUIRED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270441 -        SEE SIGNATURE IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270442 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270443 -        ** (PENTAX EGD)  AUTO-INSTRUMENT DIAGNOSIS **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270445 -         ..
270446 -    2.  Procedure: EGD  UPPER ENDOSCOPY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270448 -         ..
270449 -    3.  PENTAX INSTRUMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270450 -        10535 Hospital Way Mather CA, 95655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270452 -         ..
270453 -    4.  EGD PROCEDURE REPORT     EXAM DATE: 11/12/2019                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270457 -        VISIT #:  3200110061918                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270459 -         ..
270460 -    5.  ATTENDING:     Randall Lee, MD STATUS:     outpatient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270461 -        ASSISTING MD:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270462 -        ASSISTANT:  Nathaniel Parker, Tech and Hazel Terrado, RN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270464 -         ..
270465 -    6.  INDICATIONS: The patient is a 74 yr old male here for an EGD due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270466 -        PROCEDURE PERFORMED:   EGD diagnostic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270467 -        MEDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270468 -        TOPICAL ANESTHETIC:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270470 -         ..
270471 -    7.  CONSENT:  The risks, benefits, and alternatives to this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270472 -        procedure including but not limited to the risks of bleeding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270473 -        and bowel perforation were explained to the patient.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270474 -        patient understood and provided written informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270476 -         ..
270477 -    8.  DESCRIPTION OF PROCEDURE:  In the Sacramento VA GI Endoscopy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270478 -        Unit,  Informed consent was verified, confirmed and timeout                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270479 -        was performed. The patient was placed in left lateral                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270480 -        decubitus position.  Oxygen was administered. Continuous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270481 -        oximetric and hemodynamic monitoring was initiated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270482 -        Intravenous sedation was administered in divided doses.  After                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270483 -        a bite block was placed in the patient's mouth,  the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270484 -        GIF-1TH190-2400353 videoscope was introduced under direct                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270485 -        vision through the mouth and advanced to the   .      The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270486 -        stomach and esophagus were decompressed, and the gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270487 -        removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270489 -         ..
270490 -    9.  ADVERSE EVENTS:     There were no complications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270491 -        IMPRESSIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270492 -        RECOMMENDATIONS:    EGD & dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270494 -         ..
270495 -        Versed 3mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270496 -        fentanyl 150mcg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270497 -        Benadryl 50mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270498 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270499 -        start 1026                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270500 -        end 1038                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270502 -        1.  Proximal and mid esophageal body dilated and aperistaltic,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270503 -            with accumulation of saliva within the esophageal body that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270504 -            required irrigation and suctioning to achieve a clear view                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270505 -            of the esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270507 -             ..
270508 -        2.  Tattoo site in the esophageal body at about 31 cm again                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270509 -            noted without evidence of mass effect or ulceration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270511 -             ..
270512 -        3.  Distal esophageal mucosal defects, shallow, at prior sites                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270513 -            of ulcerations.  No evidence of active ulceration,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270514 -            inflammation or erosion.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270516 -             ..
270517 -        4.  Esophageal stricture located at the GE junction at 38-39                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270518 -            cm, estimated diameter of approximately 19 mm.  This was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270519 -            balloon dilated to 20 mm, as evidenced by mild mucosal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270520 -            tearing only after balloon dilation from 19-20mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270522 -             ..
270523 -        5.  Diaphragm located at 40 cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270525 -             ..
270526 -        6.  Normal-appearing gastric mucosa in the fundus and body.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270527 -            Gastric fundus appearance consistent with prior history of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270528 -            fundoplication with relaxation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270530 -             ..
270531 -        7.  Gastric mucosa in the antrum with mild patchy erythema but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270532 -            no ulceration, erosion, or mass effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270534 -             ..
270535 -        8.  Normal pylorus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270537 -             ..
270538 -        9.  Normal duodenum to D3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270540 -         ..
270541 -        Minor reduction in GE junction lumen since last dilation of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270542 -        November 2019.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270544 -        continue current anti-acid reflux therapies.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270545 -        repeat EGD & dilation in 2 months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270547 -         ..
270548 -        REPEAT EXAM:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270549 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270550 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270551 -        ___________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270552 -        Randall Lee, MD eSigned:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270553 -        eSigned: Randall Lee, MD 11/12/2019 9:42:10 AM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270554 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270555 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270556 -        cc:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270557 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270558 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270559 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270560 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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270573 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2706 -