CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2503 -    ..
2504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
2505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250501 - Follow up ref SDS X6 0000. ref SDS X0 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250503 - No diffuculty swallowing this cycle with LESV dilated to 20 mm 11                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250504 - weeks ago on 200310. ref SDS 0 VV6N  Doctor Lee was aware of 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250505 - coronary ablation procedures in recent weeks. ref SDS 0 XN5F  Reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250506 - no further aspiration problems, waking up choking, after Doctor Lee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250507 - ordered increased Mylanta on 190618. ref SDS 0 N27F  Reviewed pending                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250508 - issues, including frequent urination taking Pantoprazole every day,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250509 - causing dehydration now seems stabalized. ref SDS 0 UI5N  Signed blank                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250510 - consent for the procedure today, on assurance that stroke symptoms                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250511 - following prior EGD on 160617, with mild recurrence on 161213, would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250512 - not occur by holding versed below 6, and aiming for 3 mg. ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250513 - 639M  EGD dilation procedure was successful with no complications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250514 - ref SDS 0 HE9I  Gastroscope in and out took 12 minutes. ref SDS 0 UT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250515 - Versed sedation medication required only 2 mg, well below 6 mg that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250516 - caused prior stroke symptoms. ref SDS 0 CR4F  Post procedure Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250517 - Lee reported good results with LESV contracting to only 19 mm, so he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250518 - was able to dilate LESV back to 20 mm. ref SDS 0 GD5K  Ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250519 - significantly resolved over past 11 weeks, which enabled the doctor to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250520 - dilate LESV needed for better swallowing. ref SDS 0 RZ3G  Continued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250521 - improvement in ulceration and LESV dilation shows good response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250522 - treatment with prescribed medications. ref SDS 0 JK6N  Scheduled next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250523 - EGD dilation in 8 weeks on 200707 0930. ref SDS 0 XF6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250525 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250528 -  ..
2506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2508 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2509 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250901 - On 050629 meeting Primary Care swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250902 - reported. ref SDS 1 K78K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250904 -  ..
250905 - On 050714 barrium swallow test, ref SDS 2 2I4S, showed esophagus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250906 - distorted by swallowing problems. ref SDS 2 WE4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250908 -  ..
250909 - On 050816 meeting Primary Care Doctor Sandhu diagnoses achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250910 - ref SDS 3 DG8G  Ultrasound test ordered to verify initial diagnosis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250911 - swallowing and vomitting problems. ref SDS 3 6E7H  Primary Care made                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
250912 - referral to GI clinic for care to resolve swallowing problems.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250913 - ref SDS 3 0G7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250915 -  ..
250916 - On 050830 ultrasound test evaluate swallowing problems possible                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250917 - diagnosis achalasia. ref SDS 4 DG8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250919 -  ..
250920 - On 050830 results received barrium swallow test performed on 050714,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250921 - findings in the lower espohagus and gastroesophageal junction are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250922 - consistent with achalasia - recommend endoscopic examination.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250923 - ref SDS 4 6H9S                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250925 -  ..
250926 - On 050906 report ultrasound test on 050830, finds no cause for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250927 - swallowing problems and does not diagnose achalasia. ref SDS 5 BM6R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250929 -  ..
250930 - On 051202 meeting GI Clinic Doctor Lee diagnoses achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250931 - ref SDS 6 HP9H  Orders endoscopy (EGD) test to verify diagnosis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250932 - achalasia and assess for cancer. ref SDS 6 NZ5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250934 -  ..
250935 - On 051209 GI Clinic endoscopy examination preliminary findings no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250936 - evidence of cancer, ref SDS 7 0001; biopsy report should be submitted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250937 - in a few weeks to confirm status of cancer, ref SDS 7 PY5J, and if so,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250938 - then a procedure can be schedule for next month to dilate the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250939 - exophageal sphincter valve. ref SDS 7 NZ5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250941 -  ..
250942 - On 051222 biopsy reports no evidence of cancer. ref SDS 8 FT6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250944 -  ..
250945 - On 060111 received letter from Doctor Lee in the Gastrointestinal (GI)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250946 - Clinic reporting that the biopsy was negative for cancer and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250947 - infection; next step is manometry test to verify achalasia, then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250948 - treatment for achalasia. ref SDS 9 4Q3R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250950 -  ..
250951 - On 060125 manomety test scheduled for 060209 0800. ref SDS 10 GG9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250953 -  ..
250954 - On 060209 meeting at VA Mather AFB in Sacramento, test was postponed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250955 - until 060223, due to equipment failure. ref SDS 11 OW6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250957 -  ..
250958 - On 060221 Jimmy in GI Department at Sacramento VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250959 - reports manometry equipment still broken; has been sent out for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250960 - repairs and there is no date at this time on when the equipment will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250961 - be available for use at the VA. ref SDS 12 ND7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250963 -  ..
250964 - On 060330 endoscopy follow up examination at GI Department Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250965 - Medical Center - Doctor Lee finds no evidence cancer performed at VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250966 - Sacramento condition precedent treatment recover from achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250967 - ref SDS 13 VX4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250969 -  ..
250970 - On 060330 manometry test performed by Doctor Lee at VA in Sacramento,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250971 - ref SDS 13 MC7P, verifies diagnosis swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250972 - caused by achalasia, ref SDS 13 MD4N, patient meets criteria for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250973 - treatment with pneumatic dilation. ref SDS 13 MD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250975 -  ..
250976 - On 060505 Martinez VA GI clinic Doctor Lee reported equipment and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250977 - pneumatic balloon materials on hand to perform dilation for treating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250978 - achalasia; treatment delayed until diagnostic data is received from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250979 - Sacramento VA Medical Center from manometry test performed on 060330;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250980 - doctor following up to obtain data; will submit test data to patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250981 - during the week of 060508, along with a schedule to treat achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250982 - ref SDS 14 FT6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250984 -  ..
250985 - On 060614 Martinez VA GI clinic reports increased work load treating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250986 - soldiers returning from war in Iraq requires prioritizing; patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250987 - advocate, Rubin Soto, will coordinate with the GI Clinic notifying the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250988 - customer of the schedule based on current priorities. ref SDS 15 J86N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250990 -  ..
250991 - On 070220 letter to VA asks about progress getting test results from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250992 - VA in Sacramento, and scheduling surgery for achalasia, ref SDS 16                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250993 - 5R5R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250995 -  ..
250996 - On 090812 1030 continued vomitting achalasia causes weight loss 30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250997 - pounds in a few months, Primary Care physician notified GI clinic to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250998 - review schedule for dilation to relieve achalasia. ref SDS 17 7L5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251000 -  ..
251001 - On 090908 meeting GI Clinic in Martinez reports treatment for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251002 - achalasia still waiting to receive results for manometry test on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251003 - 060330, at Sacramento VA Medical Center. ref SDS 18 HX46  Prepared new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251004 - work plan to treat achalasia without manometry test results, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251005 - the doctor performed the test 3 years ago, and is so knows results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251006 - consistent with achalasia, shown on 060330 0712, ref SDS 13 MD4N;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251007 - schedules treatment for achalasia after treadmill stress test,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251008 - ref SDS 18 BU6W, to evaluate new chest pains hiking hills at Lafayette                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251009 - Reservoir which have not occurred doing extended exercise hiking 3 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251010 - 14 miles a day over the past 5 years. ref SDS 18 MY4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251012 -  ..
251013 - On 091021 report history achalasia issue during meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251014 - cardiothoracic surgery team to prepare for heart bypass surgery the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251015 - next day. ref SDS 20 NX6M  Surgery team will coordinate with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251016 - anesthesia team to provide swallowing relief during heart surgery to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251017 - prevent choking. ref SDS 20 R78O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251019 -  ..
251020 - On 091022 0700 meeting anesthesia team - Doctor Brezinski not familiar                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251021 - with achalasia - asked if achalasia has been reported to the VA?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251022 - ref SDS 21 JF9K  While being prepared with IVs for surgery, patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251023 - assists anesthesia find VA records on achalasia, ref SDS 21 2W4K;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251024 - Doctor Brezenski makes plans for patient care and safety so that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251025 - achalasia does not risk death during heart surgery. ref SDS 21 GX4J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251027 -  ..
251028 - On 091022 cabg x4 cardiothoracic surgery San Francisco Medical Center.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251029 - ref SDS 21 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251031 -  ..
251032 - On 091030 0800 at 1406 meeting with Doctor Stewart at San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251033 - Medical Center during recovery from heart surgery, proposes Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251034 - Myotomy surgery rather than pneumatic (balloon) dilation as more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251035 - effective and longer lasting solution to recover from swallowing and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251036 - vomitting problems caused by achalasia. ref SDS 24 KE3B                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251038 -  ..
251039 - On 091030 0800 at 1430 received documentation from GI Department at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251040 - San Francisco Medical Center - review shows 3 different treatments for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251041 - achalasia - pills, pneumatic dilation, Heller Myotomy surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251042 - ref SDS 24 495I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251044 -  ..
251045 - On 091030 0800 at 1440 meeting cardiothoracic surgery team; Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251046 - Ratcliff concerned about how to maintain nutrition for the patient to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251047 - recover from heart surgery while digestion remains problematic due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251048 - achalasia; proposes feeding tube for several months until Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251049 - Myotomy surgery. ref SDS 24 03GF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251051 -  ..
251052 - On 091216 Heller Myotomy surgery at San Francisco VA Medical Center to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251053 - recover from achalasia. 091216 0600, ref SDS 36 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251055 -  ..
251056 - On 100202 meeting with Doctor Lee - report swallowing and vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251057 - problems 3 months after Heller Myotomy surgery.  Doctor explains                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251058 - achalasia disease breaks nerve connections from the brain that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251059 - contract the esophagus to force food and liquid from the mouth through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251060 - the esophagus; as well broken nerve connections prevent the lower                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251061 - esophageal sphincter valve (LESV) to relax so that content can pass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251062 - into the stomach.  Without esophageal contractions, food and liquid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251063 - can only reach the stomach with gravity, but since the LESV won't                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251064 - relax the patient continues to have swallowing and vomitting problems,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251065 - despite Heller Myotomy surgery on 091216, intended to maintain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251066 - adequate opening into the stomach. ref SDS 47 485W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251068 -  ..
251069 - On 100305 meeting at GI Clinic in Martinez, EGD procedure dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251070 - from 11 to 15 mm. ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251072 -  ..
251073 - On 100827 meeting at GI Clinic in Martinez, EGD procedure dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251074 - from 11 to 15 mm. ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251076 -  ..
251077 - On 101210 EGD procedure dilated esophageal sphincter valve (LESV)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251078 - without sedation, ref SDS 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 B2 935L; a second                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251180 - letter scheduled prodedure on 140509 0900. ref SDS B2 5D7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251182 -  ..
251183 - On 140401 1659 ordered refill Omeprazole; none are remaining; need                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251184 - Doctor Lee to order new prescription to increase refills. ref SDS B3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251185 - 4P5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251187 -  ..
251188 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251189 - center in Sacramento, Mather. ref SDS B5 K37G  Pre-op preperation went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251190 - well - IV setup on first stick. ref SDS B5 EP75  Doctor ordered refills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251191 - for Omeprazole. ref SDS B5 AW5O  Doctor patient partnership continues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251192 - to progress with doctor reading up on patient history to be prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251193 - for effective meeting. ref SDS B5 ZZ6J  Doctor Lee recalled today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251194 - having made timely referral for having heart surgery, enabling patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251195 - to recover and Half Dome 4 years later. ref SDS B5 0N6I  Reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251196 - swallowing and vomitting problems reduced past 6 months with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251197 - triamcinolone steriod injections to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251198 - ref SDS B5 VV6N  Doctor Lee dilated LESV contracted to only 16.5 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251199 - over past 6 months with triamcinolone steriod injections to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251200 - contraction; he dilated LESV back to 18 MMy, ref SDS B5 5H5J, scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251201 - next EGD dilation in 6 months since this worked well the past 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251202 - with triamcinolone steriod injections. ref SDS B5 549I  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251203 - explained that since there was no tearing of LESV during procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251204 - today, triamcinolone steriod was not injected into LESV to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251205 - contraction. ref SDS B5 I167  Progress notes report small tearing of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251206 - LESV during dilation procedure. ref SDS B5 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251208 -  ..
251209 - On 140718 1017 planning for notifying VA to update current fill date                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251210 - for Omeprazole. ref SDS B9 U88L  Kathy visited VA in Sacramento, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251211 - requested changing refill date for Omeprazole to 140718. ref SDS B9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251212 - OL5K  VA representative called customer, and said Doctor Lee would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251213 - call back later that day to consider action on updating scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251214 - refill date of Omeprazole to 140718. ref SDS B9 U76M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251216 -  ..
251217 - On 140810 1839 letter to Doctor Lee requesting EGD dilation with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251218 - triamcinolone injection soonest, if cancellation occurs; but, not an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251219 - emergency, ref SDS C1 W83K, based on history rising vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251220 - swallowing problems, shown in patient history case study on 120101,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251221 - beginning 140712. ref SDS 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 C2 EX78                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251229 -  ..
251230 - On 141014 0943 Kathy visited VA Medical Center in Sacramento and met                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251231 - with Lapria again, who advised that the VA responded in a letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251232 - 141001, to the letter on 140810, and further scheduled a meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251233 - Doctor Lee on 141121 1530. ref SDS C3 QJ5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251235 -  ..
251236 - On 141103 2152 submitted agenda for meeting with Doctor Lee at VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251237 - Sacramento Medical Center on 141107 0800, for next EGD dilation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251238 - ref SDS C4 K37G  Submit record showing normal swallowing occurs longer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251239 - with triamcinolone steriod injection to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251240 - ref SDS C4 3U97  Request schedule next EGD dilation in 4 months, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251241 - if LESV does not contract, then schedule following EGD dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251242 - months. ref SDS C4 3U66  Notified results of Half Dome hike.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251243 - ref SDS C4 3U6Y                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251245 -  ..
251246 - On 141107 0800 EGD dilation procedure - setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251247 - sedation required 3 sticks. ref SDS C5 5W5I  Meeting Doctor Lee guided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251248 - by agenda facilitated collaboration through doctor patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251249 - partnership. ref SDS C5 VV6N  Doctor explained increased difficulty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251250 - swallowing due to experiment omitting triamcinalone steriod injection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251251 - on prior procedure, ref SDS C5 4U8I, shown by LESV contracting back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251252 - from 15 mm. ref SDS C5 T55I  Progress Notes report finding ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251253 - and hiatal hernia. ref SDS C5 MG6N  Photographs seem to show                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251254 - significantly different condition of fundoplication from a year                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251255 - earlier. ref SDS C5 I74I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251257 -  ..
251258 - On 150319 0800 meeting Doctor Lee in GI Clinic VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251259 - Sacramento report swallowing improved with triamcinalone steriod                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251260 - injections on 141107 EGD dilation procedure. ref SDS D1 0M6I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251261 - Lee advised that increased orange juice consumption aids digestion,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251262 - and presents no health risks. ref SDS D1 YF5M  Scheduled next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251263 - dilation procedure on 150421 1300. ref SDS D1 PS4O  Fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251264 - failure increases acid burn that caused ulceration with hiatal hernia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251265 - with increased recurrance achalasia. ref SDS D1 O56O  Doctor Lee will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251266 - make referral to Doctor Stewart at General Surgery VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251267 - in San Francisco for consideration of "redo" fundaplicaiton.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251268 - ref SDS D1 JQ5J  Doctor Lee completed Progress Notes for EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251269 - on 141107. ref SDS D1 PS53  Doctor Lee will recommend Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251270 - order CT test to evaluate recurrance achalasia due to failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251271 - fundoplication. ref SDS D1 TH5M  This test can include coronary CTA to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251272 - evaluate regression atherosclerosis. ref SDS D1 GB56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251274 -  ..
251275 - On 150420 1752 submitted letter to Doctor Lee with agenda for meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251276 - the next day on 150421 1300 for EGD dilation. ref SDS D3 0M6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251278 -  ..
251279 - On 150421 Met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251280 - (Mather). ref SDS D4 K37G  No difficulties setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251281 - sedation. ref SDS D4 5W5I  Reported pain level 2 right knee MCL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251282 - ref SDS D4 LO9K  Doctor Lee advised referral to San Francisco will be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251283 - filed after EDG dilation procedure (this day) to evaluate loosening                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251284 - fundoplication. ref SDS D4 DZ4I  Patient reported difficulty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251285 - swallowing this cycle did not occur until 4 weeks or so, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251286 - triamcinalone steriod was injected during prior procedure on 141107,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251287 - ref SDS D4 P55L, and shown by EGD dilation LESV from 16.5 mm back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251288 - 18 mm. ref SDS D4 HU42  Progress Notes report findings of hiatal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251289 - hernia. ref SDS D4 QD6O  Impression today that ulceration has subsided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251290 - to mere errosions seems promising. ref SDS D4 PXXY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251292 -  ..
251293 - On 150514 0130 letter to Doctor Lee requests file Progress Notes for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251294 - EGD Dilation today, and make referral to Doctor Stewart, to prepare                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251295 - for meeting with Doctor Lee scheduled on 150521. ref SDS D6 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251297 -  ..
251298 - On 150521 0800 meeting with Doctor Lee at VAMC in Sacramento -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251299 - concensus uncharacteristic vomitting after recent EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251300 - procedure on 150421, due to patient not eating slowly with small bites                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251301 - and drinking liquids frequently, especially when eating meat products                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251302 - that have high viscocity with esophageal tissue, and so tends to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251303 - stick, causing vomitting. ref SDS D8 WT9L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251305 -  ..
251306 - On 150526 1300 meeting with Doctor Stewart Chief General Surgery VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251307 - Medical Center San Francisco, review record indicating ulceration LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251308 - caused by reflux backwash into esophagus. ref SDS D9 3E4I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251309 - Stewart explained redo Dor Fundoplication required for "repairing"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251310 - original surgery, presents high risk of collateral damage. ref SDS D9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251311 - GT5G  Considered increase dose Omeprazole (PPI) since ad hoc                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251312 - experience occasionally taking 3 and sometimes 4 pills instead of only                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251313 - 1 pill per day seemed to reduce reflux based on examination showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251314 - ulceration of LESV declined; this would avoid need to redo Dor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251315 - Fundoplication. ref SDS D9 5Y4I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251317 -  ..
251318 - On 150616 1624 received photographs on CD in word.docx file from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251319 - Phillip in ROI Department at VA MC in Sacramento (Mather) showing Dor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251320 - fundoplication in tact on 131115, beginning to unravel on 140507,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251321 - further unraveled on 141107, and unraveled on 150421. ref SDS E2 XW6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251323 -  ..
251324 - On 150623 1300 during follow up meeting, Doctor Stewart discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251325 - again increasing Omeprazole PPI to resolve ulceration of LESV rather                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251326 - than risk difficult surgery to redo Dor fundoplication, and she                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251327 - ordered prescription for H2 blocker to supplement Omeprazole PPI.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251328 - ref SDS E3 WW5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251330 -  ..
251331 - On 150624 0924 letter notified Doctor Lee of work plan to try                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251332 - controlling ulceration of LESV by increasing PPI with Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251333 - rather than chance performing high risk surgery to repair Dor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251334 - fundoplication, and that Doctor Stewart ordered H2 Blocker for Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251335 - Lee to consider supplementing PPI to control acid reflux. ref SDS E4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251336 - OP91                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251338 -  ..
251339 - On 150624 0924 at 1344 Doctor Lee called and will order new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251340 - prescription for PPI increasing Omeprazole from 20 mg twice per day to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251341 - 40 mg twice per day. ref SDS E4 L861                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251343 -  ..
251344 - On 150925 0336 request switch back to Omeprazole 20 mg twice per day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251345 - in order to reduce severe side effects of dehydration from frequent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251346 - urination causing scaling, peeling, bleeding feet; lower dose                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251347 - Omeprazole enables hiking to raise HDL required to regress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251348 - atherosclerosis plaques, thereby lowering risks of CVD and CAD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251349 - ref SDS E6 5G8T  As a result, Pharmacy VA Medical Center San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251350 - entered new prescription for (PPI) Omeprazole 20 mg. ref SDS E6 FK66                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251352 -  ..
251353 - On 150925 0336 VA scheduled next meeting for EGD dilation on 151204                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251354 - 0800. ref SDS E6 SR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251356 -  ..
251357 - On 151002 1820 Doctor Lee returned call; will order Omeprazole 20 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251358 - prescription sufficient until next EGD Dilation procedure on 151204,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251359 - and complimenting prescription entered on 150925 for only 1 month.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251360 - ref SDS E7 NV5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251362 -  ..
251363 - On 151012 1151 VA Internet Pharmacy lists updated Omeprazole 20 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251364 - prescription. ref SDS D5 0C5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251366 -  ..
251367 - On 151204 0800 met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251368 - (Mather); initial administration went well. ref SDS F4 GD4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251369 - Preparation for the procedure was professional; no difficulties                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251370 - setting IV for conscious sedation today. ref SDS F4 544G  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251371 - reported not receiving letter with agenda for the meeting today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251372 - submitted on 151201. ref SDS F4 VV6N  Patient difficulty swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251373 - occurred after 5 months, because triamcinalone steriod injected prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251374 - procedure on 150421.  Swallowing difficulty/vomiting increased over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251375 - the next 3 months indicates dilate LESV 18 mm and doing EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251376 - in 6 rather than 8 months. ref SDS F4 P55L  Asked about Baking Soda to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251377 - clear throat in order to avoid vomitting, and prevent ulceration LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251378 - alternative to Omeprazole in order to avoid side effects causing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251379 - dehydration. ref SDS F4 G53K  Performing EGD dilation procedure went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251380 - smoothly, with no difficulties. ref SDS F4 7V6I  Post procedure Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251381 - Lee reported LESV contracted to 10 mm, the worst results in patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251382 - history, indicating 2 month delay performing procedure this cycle was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251383 - harmful. ref SDS F4 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251385 -  ..
251386 - On 151210 meeting Doctor Lee after EGD on 151204, changed prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251387 - of Omeprazole (PPI) to 20 mg every other day to eliminate or reduce                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251388 - dehydration from frequent urination, and in order for feet to recover                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251389 - from peeling, cracking, bleeding so that hiking can be performed at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251390 - level of 300 miles per month required to raise HDL > 60, required to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251391 - regress athersclerosis. ref SDS F7 J56O  Doctor prescribed adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251392 - Famotidine an H2 blocker taken once a day to compliment Omeprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251393 - ref SDS F7 YL3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251395 -  ..
251396 - On 160325 0900 Diffuculty swallowing this cycle began about 1 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251397 - after prior EGD dilation on 151204. ref SDS G8 P55L  Reported using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251398 - baking soda to relieve reflux that prevents ulceration LESV; this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251399 - reduced Omeprazole in order to avoid dehydration. ref SDS G8 Z84H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251400 - Progress Notes report there is no longer any erosive esophagitis and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251401 - there is no evidence of mass effect, which implies better acid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251402 - suppression compared to previous examination December 2015.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251403 - ref SDS G8 PXXY  EGD dilation procedure went smoothly, with no reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251404 - of difficulties. ref SDS G8 7V6I  Post procedure Doctor Lee reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251405 - LESV contracted to 9.5 mm, the smallest in patient history, indicating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251406 - 2 month delay to 8 months performing procedure in December causing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251407 - continual injury. ref SDS G8 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251409 -  ..
251410 - On 161128 1119 called VA GI Clinic in Sacramento; LaPreia said meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251411 - Doctor Lee scheduled for 161214, has been changed to the next day on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251412 - 161215 1200. ref SDS K4 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 K7 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 P9 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 Q2 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 S0 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 X6 NU8L, ref SDS X0 NU8L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251806 - EGD treatment with Doctor Lee today, was scheduled by Jessica on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251807 - 200505 0830. ref SDS X8 JJ5N   On 200514 1220 Brad called and changed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251808 - the meeting from 1030 to 0930, ref SDS Y1 NU8L, so will arrive OA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251809 - 0850.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251811 -  ..
251812 - Currently, Doctor Lee has been doing EGD procedures every 8 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251813 - The EGD scheduled on 200505, was cancelled due to risk of spreading                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251814 - coronavirus. ref SDS X8 NU8L  Schedule was updated by Jessica                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251815 - extending procedures to Jan of next year, reported on 200110 0830.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251816 - ref SDS X0 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 - Yesterday, drove to Sacramento from Concord on Monday, and stayed at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251826 - Kathy's house about 3 miles from VAMC Sacramento.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251827 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251828 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251830 -  ..
2519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2521 - 0855                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252201 - Arrived at VAMC Sacramento.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252203 -  ..
252204 - Shanty did check-in to GI Department at the customer counter.  She was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252205 - as usual enthusiastic and helpful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252207 -  ..
252208 - Rosie did vitals.  She looks great recovering from lung cancer.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252210 -  ..
252211 - Vitals were taken today, and found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252212 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252213 -            Weight.................. 181                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252214 -            BP...................... 124 65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252215 -            HR (pulse).............. 77                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252216 -            Oxygen.................. 100                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252217 -            Temp.................... 96.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252218 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252220 -  ..
252221 - Kathy cell phone for designated driver...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252225 -  ..
252226 - Kathy signed the discharge form affirming she will be designated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252227 - driver, and responsible to facilitate no driving for 24 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252229 -  ..
252230 - Went from vitals into prep room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252231 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252232 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252233 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252234 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252236 -  ..
2523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2525 - 0915                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252601 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252602 - 
252603 - Follow up ref SDS X6 EP75, ref SDS X0 EP75.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252604 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252605 - No objections nor concerns today, as occurred previously on 161115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252606 - 0800, ref SDS J9 WA5I, and again on 161130 1038. ref SDS K5 EP75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252608 -  ..
252609 - Saw Jennifer to say hello today.  She was kind remembering me.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252611 -  ..
252612 - Did not see Clair today, to say hello.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252614 -  ..
252615 - In the GI Clinic, Hazel directed me to a gurney.  She helped with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252616 - patient gown and setup on the gurney.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252618 -  ..
252619 - Hazel entered patient history in the computer.  Most information                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252620 - entered today, for patient identification and medical history is the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252621 - same.  Hazel entered recent changes:  left atrial ablation procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252622 - to end atrial fibrillation, reported on 200430 0700. ref SDS X7 IW9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252623 - Second ablation in the right atrial was done a few weeks ago on 200511                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252624 - 0546. ref SDS Y0 244I  Patient now taking Clopidogrel, Apixaban blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252625 - thinner and Metoprolol to slow heart rate, also reported on 200103                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252626 - 0700. ref SDS W5 1X30  Clapidogrel and Apixaban were stopped 2 days                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252627 - ago on 200527, shown in case study on 200101 0702. ref SDS W4 N19H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252628 - Also paused Metoprolol this morning, ref SDS W4 T47G, IAW letter to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252629 - Doctor Simpson submitted on 200109 2121. ref SDS W9 WG9R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252631 -  ..
252632 - Hazel asked about pain?  Reported level 0.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252634 -  ..
252635 - Later saw Danis in the hallway, applying personal protection equipment                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252636 - for nurses and doctors to perform procedures.  Danis gave me a hug                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252637 - despite concern about coronavirus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252639 -  ..
252640 - Hazel said Doctor Lee is already on site and waiting to do this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252641 - procedure because his earlier procedure was cancelled.  She said the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252642 - patient did not have a driver.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252644 -  ..
252645 - Gracie set catheter IV for sedation.  She asked for best location to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252646 - get a good vein.  Explained inner right elbow right side vein used                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252647 - last month with success on 1st stick.  Did not do 10 pushups with feet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252648 - on gurney to improve blood flow.  Veins develop adhesions (scar                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252649 - tissue) that take time to heal, and prevent blood flow into the IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252650 - needle.  This morning ran hot water on right forearm in the shower to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252651 - dilate veins, which helped to get blood flow on 1 stick today.  Gracie                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252652 - chose site on left side of right inner arm about 2" below elbow.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252653 - was pain level 7.  She was sort of successful getting blood flow on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252654 - 1st stick, but was worried it might not be adequate for injecting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252655 - drugs during the procedure.  Gracie consulted with a colleague, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252656 - decided to remove the 1st catheter and do another.  For the 2nd stick,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252657 - she used the location initially recommended at inner right side of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252658 - elbow.  This was pain level 3.  It was successful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252660 -  ..
252661 - Case study on sticks required to set catheter is reported on 110429                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252662 - 1230. ref SDS 76 UO3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252664 -  ..
252665 - Gracie is nurse in the room today.  Hazel set blood pressure cuff and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252666 - EKG probes.  Hazel said EKG is reporting normal sinus heart rythm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252667 - this morning.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252668 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252669 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252670 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252671 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252672 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252673 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252675 -  ..
2527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2529 - 0932                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253001 - Meeting Doctor Lee and Consent for Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253002 - 
253003 - Follow up ref SDS X6 GG6G, ref SDS X0 GG6G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253005 -  ..
253006 - Doctor Lee asked questions on patient history to verify ready for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253007 - procedure, e.g., no allergies, and NPO after midnight to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253008 - conflicts with anesthesia; no health problems, e.g., no diabetes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253009 - alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253011 -  ..
253012 - Doctor Lee asked about medication protocol?  Reported protocol he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253013 - prescribed after EGD on 190416 1000, ref SDS T9 JK6N, modified                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253014 - recently adding Apixaban and Metoprolol to treat paroxysml atrial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253015 - afibrillation, reported on 200103 0700. ref SDS W5 VT9J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253017 -  ..
253018 - This morning he confirmed the following prescription...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253019 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253020 -        Famotidine................0700.... 2 40mg pills in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253021 -        Metoprolol................0700.... 1 25 mg pill in morning taken with PPI and food                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253022 -        Clopedigrel...............0700.... 1 75 mg pill in morning taken with PPI and food                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253023 -        Apixaban..................0700.... 1 05 mg pill in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253025 -         ..
253026 -        Hiking - most everyday taken an hour before start hikes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253027 -        Naproxen.......................... 2 200 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253028 -        Gabapentin........................ 1 300 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253029 -        Glucosamine Chondroitin...........    80 ml                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253030 -        Oxycodone......................... sometimes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253031 -        Tramadol.......................... sometimes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253032 -        Nitroglycerin  (prescribed, but not likely to be taken)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253034 -         ..
253035 -        Pantoprazole..............1700.... 1 40mg pill 30 min before dinner every day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253036 -        Atorvastatin..............1830.... 1 10mg pill every other day hour after dinner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253037 -        Ezetimibe.................1830.... 1 10mg pill every other day hour after dinner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253038 -        Mylanta...................2000.... 40 ml OA 2000 - 1 hour after statins                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253039 -        Calcium Carb (Tums).......2030.... 2 500mg pills 30 min after Mylanta                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253040 -        Famotidine................2200.... 2 40mg pills before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253041 -        Apixaban..................2200.... 1 05 mg pill before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253042 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253043 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253044 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253046 -  ..
253047 - Paroxysmal Atrial Fibrillation Treated Ablation Pulmonary Vein Isolation on 200430                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253048 - Right Atrial Flutter Treated Ablation on 200511                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253049 - Vision Diminished Fatigue Sleepy Taking Metoprolol Treatment PAF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253050 - 
253051 - Follow up ref SDS X6 XN5F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253052 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253053 - On 200306 1631 letter notified Doctor Pellegrini in Cardiology at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253054 - VAMCSF that new symptoms have occurred of diminished vision and eye                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253055 - strain pain, and physical fatigue, sleepiness from taking metropolol                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253056 - to treat PAF.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253058 -  ..
253059 - On 200227 0954 received Polar Vantage V wearable device to track time,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253060 - HR and other diagnostics related to PAF. ref SDS X4 9X5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253062 -  ..
253063 - On 200430 0700 ablation on left atrial performed by Doctor Pellegrini.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253064 - ref SDS X7 9C9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253066 -  ..
253067 - On 200509 1517 HR elevated; Doctor Pellegrini suspected atrial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253068 - flutter, went to ER at VAMCSF. ref SDS X9 9C9M   Treated with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253069 - Adenosine to momentarily stop the heart that resets normal heart rate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253070 - ref SDS X9 T458  HR test data submitted to Doctor Pellegrini.  She                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253071 - ordered patient admitted to hospital for right atrial flutter; will be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253072 - treated with 2nd ablation on Monday, 200511. ref SDS X9 NE3H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253074 -  ..
253075 - On 200511 0546 at 1342 went to ASU for preparation to do ablation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253076 - ref SDS Y0 244I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253078 -  ..
253079 - On 200527 0930 telecon meeting with Doctor Pellegrini advised ablation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253080 - procedures successfully treated atrial fibrillation and atrial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253081 - flutter. ref SDS Y2 JJ6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253083 -  ..
253084 - This morning, Doctor Lee advised that he has read progress notes for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253085 - ablation on the left atrial performed 200430 0700. ref SDS X7 9C9M  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253086 - also reviewed progress notes for ablation on the right atrial,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253087 - performed on 200511 0546. ref SDS Y0 244I  Based on the record and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253088 - patient favorable response to these procedures, he feels the EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253089 - procedure can be safely performed today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253090 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253091 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253092 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253094 -  ..
253095 - Swallowing Has Been Effective Past 8 Weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253096 - 
253097 - Follow up ref SDS X6 VV6N, ref SDS X0 VV6N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253098 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253099 - Vomitting 100% dinner on 200517, see case study on 200101 0702.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253100 - ref SDS W4 TTQP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253102 -  ..
253103 - Could have been spicy lasagna sause.  Stomach hurt for next 2 wees;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253104 - might be side effects of drug combinations added for ablation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253106 -  ..
253107 - Discussed drugs with Doctor Pellegrini on 200527 0930. ref SDS Y2 MU4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253109 -  ..
253110 - Eating regimen is shown in case study of daily diet, medication,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253111 - exercise and vitals, reported on 200101 0702. ref SDS W4 UVXU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253113 -  ..
253114 - Reviewed eating practice - small bites taken with liquid, and mixing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253115 - meat products with other food enables each bite to slip past small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253116 - opening of LESV until next EGD dilates again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253118 -  ..
253119 - Doctor Lee glanced through case study on 190101 showing exercise,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253120 - diet, medication and vitals.  He feels record on typical diet and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253121 - eating for example on 191118, aligns with requirments for effective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253122 - swallowing under achalasia, ref SDS S9 VQUY; and on 191221.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253123 - ref SDS S9 QVPV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253125 -  ..
253126 - Bubbles clogging LESV seem reduced this cycle, especially past few                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253127 - weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253129 -  ..
253130 - Burping seems better controlled compared to years past.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253131 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253132 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253133 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253135 -  ..
253136 - Digestion Deficit Woke Up Choking Aspirated Reflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253137 - 
253138 - Follow up ref SDS X6 N27F, ref SDS X0 N27F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253139 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253140 - No aspiration issues this past cycle, since Doctor Lee ordered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253141 - increased Mylanta on 190618 0730. ref SDS U7 8468                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253142 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253143 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253144 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253146 -  ..
2532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2534 - 0947                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253501 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253502 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253503 - 
253504 - Follow up ref SDS X6 KT9M, ref SDS X0 KT9M.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253506 - Doctor Lee presented a digital tablet and requested signature to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253507 - consent for the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253509 -  ..
253510 - Noted that signature is entered on completely black screen, required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253511 - without reading online documents.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253513 -  ..
253514 - Advised that signature is based on following understandings...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253516 -         ..
253517 -    1.  Frequent urination taking Pantaprazole everyday seems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253518 -        stabalized over the past treatment cycle, at rate that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253519 -        minimizes dehydration, shown on 200101 0701. ref SDS W3 PVTP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253520 -        Occasionally, there will be nights getting up 4 - 6 times,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253521 -        e.g., on 191113 and 191113, ref SDS W3 J99F; however this is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253522 -        not persistent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253524 -         ..
253525 -    2.  Voice scratchy about the same following examination and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253526 -        recommendations by Doctor Lee during prior EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253527 -        190917 0730. ref SDS V9 HE9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253529 -         ..
253530 -        Voice worse past few weeks, even when concentrating on washing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253531 -        throat with carbonated beverage after each bite of food during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253532 -        meals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253534 -         ..
253535 -        Voice overall better after recent increase dilating LESV to 20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253536 -        mm has improved swallowing, compared to prior practice dilating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253537 -        to only 18 mm.  This has also improved voice function.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253539 -  ..
253540 - Asked Gracie about my voice today.  She said voice seems little                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253541 - scratchy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253543 -  ..
253544 - Doctor Lee concurred voice diminished worse this morning, as it has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253545 - been in the past.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253548 -         ..
253549 -    3.  Fundoplication failing, causing continual stricture of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253550 -        requiring frequent dilation.  Doctor planned to research this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253551 -        issue during meeting on 171115 1142. ref SDS O8 XA4F  Discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253552 -        again during meeting on 180124 1130. ref SDS P6 CT56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253554 -         ..
253555 -        On 180627 1300 Doctor Patel seemed to say GI Clinic at VAMCSF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253556 -        has investigated viability of gastroscope fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253557 -        procedures.  He seemed to further advise that the clinic has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253558 -        referred patients for gastroscope full fundoplication, but not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253559 -        to repair fundoplication. ref SDS R0 JX9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253561 -         ..
253562 -        We reviewed the record in this case that Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253563 -        performed Dor fundoplication on on 091216, as shown Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253564 -        Notes received on 100928 0706. ref SDS 56 VK8F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253566 -         ..
253567 -        At tht time on 180627 1300 asked Doctor Patel to review with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253568 -        the GI team prospects to repair Dor Fundoplication in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253569 -        reduced reflux that continually causes stricture that closes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253570 -        down LESV, requiring repeated EGD dilations on close intervals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253571 -        ref SDS R0 HP4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253573 -         ..
253574 -        Discuss with Samantha Southi developing proposal for using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253575 -        gastroscope to reposition Dor fundoplication for enhanced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253576 -        reflux control.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253578 -  ..
253579 - Did not discuss today, because seem to be managing reflux well enough                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253580 - to minimize formation of stricutre, so that swallowing is not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253581 - impaired, thus avoiding vomiting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253582 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253583 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253585 -         ..
253586 -    4.  Hiatal Hernia - can this subside or otherwise improve over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253587 -        time with any action by patient, similar to ulceration of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253588 -        recovering by ending naproxen, and adding carbonated beverage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253589 -        to washout esophagus during meals?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253591 -         ..
253592 -        What drives worsening of hiatal hernia?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253594 -  ..
253595 - Did not discuss this today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253596 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253597 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253599 -         ..
253600 -    5.  Dilation 19 - 20 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253602 -         ..
253603 -        Assess today, toward maintaining reduced medication dose, or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253604 -        increase dose on findings of ulceration LESV recurrance.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253606 -  ..
253607 - Today, Doctor Lee dilated LESV from 19/20 to 20 mm, reported in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253608 - Progress Notes shown below. ref SDS W0 X95J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253609 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253610 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253612 -         ..
253613 -    6.  Conscious Sedation with versed - asked Doctor Lee to limit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253614 -        injection of versed to 3 mg, if feasible, and in no case do not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253615 -        exceed 5 mg, in order to avoid stroke symptoms on 160617 1637,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253616 -        ref SDS H1 5F6F, following EGD earlier that day when procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253617 -        took 30 minutes, 100% longer, and so versed was increased to 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253618 -        mg, reported on 160617 0800, ref SDS H0 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253620 -  ..
253621 - This was discussed with Doctor Lee, and with Gracie, who will be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253622 - administering drugs, and so this briefing was helpful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253623 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253624 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253625 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253626 -    7.  Barium Swallow Test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253628 -  ..
253629 - Did not discuss.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253630 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253631 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253632 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253633 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253635 -  ..
2537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2538 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2539 - 1004                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2540 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254001 - OR EGD Dilation with Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254002 - EGD Dilation Procedure in OR Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254003 - 
254004 - Follow up ref SDS X6 HE9I, ref SDS X0 HE9I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254005 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254006 - Gracie and Monique were dressed in patient protection equipment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254008 -  ..
254009 - Gracie connected sensors to monitor vitals.  She connected IV to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254010 - saline drip, ready to apply conscious sedation drugs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254012 -  ..
254013 - EKG showed sinus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254015 -  ..
254016 - Everything went smoothly in the OR today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254018 -  ..
254019 - Gracie squirted lidocaine in the mouth, and said to gargle for 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254020 - seconds.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254022 -  ..
254023 - After placing a bite block, Gracie covered the face with a plastic cup                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254024 - connected to oxygen.  This is a new type of equipment to reduce                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254025 - exposure to infectious virus, in this case coronavirus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254027 -  ..
254028 - Gracie applied versed for conscious sedation using the catheter, which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254029 - she set earlier in Preparation, per above. ref SDS 0 JA4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254030 - Understandings were applied on sedation protocol reviewed with Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254031 - Lee and agreed in signing the consent, per above. ref SDS 0 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254033 -  ..
254034 - Monique was the technician.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254036 -  ..
254037 - The team then did the EDG/dilation procedure with Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254039 -  ..
254040 - Gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254041 - Start Time........... 1034                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254042 - Procedure Stop....... 1046                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254044 -  ..
254045 - Total time for procedure...... 12 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254047 -  ..
254048 - Nursing Procedural Sedation & Analgesia Flow Sheet Record - Page 1 of 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254049 - Versed total................   2 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254050 - Fentanyl total.............. 100 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254051 - Benadryl....................  50 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254052 - Lidocaine...................   5 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254053 - IV Fluids normal saline..... 200 ML  NSIV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254054 - Triamcinalone...............   0 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254056 -  ..
254057 - During procedure while asleep...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254059 -  ..
254060 - Blood pressure 152/83 to 113/69  Heart Rate 72 - 56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254061 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254062 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254064 -  ..
254065 - Nurses note says patient feeling anxious; has minor cut on upper lip.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254067 -  ..
254068 - EKG shows patient in sinus...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254069 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254070 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254072 -  ..
254073 - This aligns with initial EKG readings during prep, above. ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254074 - XU4J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254075 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254076 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254077 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254079 -  ..
254080 - LESV Contact 1 MM Dilation 20 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254081 - Meeting Doctor Lee EGD Dilation 20 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254082 - Ulceration Resolved Meeting Doctor Lee EGD Dilation 20 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254083 - 
254084 - Follow up ref SDS X6 5H5J, ref SDS X0 5H5J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254085 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254087 -  ..
2541 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2542 - 1119                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254301 - Woke in recovery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254303 -  ..
254304 - Post Procedure Care Record...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254306 -  ..
254307 - Blood pressure 124/70 to 133/76  Heart Rate 69 - 74                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254308 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254309 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254311 -  ..
254312 - Doctor Lee arrived.  He reported good results again today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254314 -  ..
254315 - LESV contracted only 1 mm from 20 back to 19 mm, showing continuing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254316 - improvement compared to severe weekly contractions, evident from case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254317 - study below. ref SDS 0 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254319 -  ..
254320 - Doctor Lee explained dilating the baloon from 19 mm to 20 mm.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254321 - was slight bleeding, but no actual breaks in LESV tissue.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254323 -  ..
254324 - Versed was limited today, to 2 ml, as discussed during the meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254325 - before the procedure, per above. ref SDS 0 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254327 -  ..
254328 - The doctor indicated current medication and eating regimens, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254329 - above, ref SDS 0 FV8H, should continue to maintain recovery from prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254330 - achalasia difficulties, i.e., work today demonstrated strong response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254331 - to treatment recovering from esophageal ulceration, including omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254332 - Triamcinalone.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254333 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254334 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254335 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254336 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254337 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 X6 XM3J, ref SDS X0 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 -          2.5   200529   40  160     19     20......0.0.....2......50......100.....10.... ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260418 -          2     200310   40  160     19     20......0.0.....3......50......150.....10.... ref SDS X6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260419 -          2     200110   40  160     19     20......0.0.....3......50......150.....10.... ref SDS X0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260420 -          2     191112   40  160     19     20......0.0.....3......50......150.....10.... ref SDS W0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260421 -          1     190917   40  160     19     20......0.0.....3......50......150.....10.... ref SDS V9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260422 -          1     190813   40  160     19     20......0.0.....3......50......150.....10.... ref SDS V6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260423 -          1     190709   40  160     20     20......0.0.....3......50......150.....10.... ref SDS V2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260424 -          1     190618   40  160     19     20......0.0.....3......50......150.....10.... ref SDS U7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260425 -          1     190521   40  160     18     20......0.0.....3......50......200.....10.... ref SDS U3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260426 -          1     190416   40  160     18     20....100.0.....3......50......200.....10.... ref SDS T9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260427 -          1     190319   40  160     19     20......0.0.....3......50......150.....10.... ref SDS T7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260428 -          1     190215   40  160     19     20......0.0.....3......50......150.....10.... ref SDS T3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260429 -          1     190118   40  160     18     20......0.0.....3......50......150.....10.... ref SDS S7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260430 -          1     181218   40  160     18     20......0.0.....4......50......150.....10.... ref SDS S7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260431 -          1     181127   40  160     18     20......0.0.....3......25......250.....10.... ref SDS S6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260432 -          1     181030   40  160     18     20......0.0.....3......25......250.....10.... ref SDS S4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260433 -          1     181002   40  160     18     20......0.0.....3......25......250.....10.... ref SDS S3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260434 -          1     180904   40  160     16.5   19......0.0.....3......25......250.....10.... ref SDS R7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260435 -          1     180814   40  160     16     19......0.0.....3......25......250.....10.... ref SDS R5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260436 -          0.5   180713   40  160     16.5   18......0.0.....3......25......250.....10.... ref SDS R1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260437 -          2.5   180627   40  160     12     16.5....0.0.....3......25......250.....10.... ref SDS Q9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260438 -          2     180417   40  160     16.5   19......1.0.....3......25......250.....10.... ref SDS P9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260439 -          1.50  180227   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260440 -          1.25  180109   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260441 -          1     171128   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS P0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260442 -          2     171031   40  160     15.5   18......1.0.....4......25......250.....10.... ref SDS O6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260443 -          1.53  170905   80   80     15     18......1.0.....3......25......250.....10.... ref SDS O2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260444 -          1.53  170516   80   80     16.5   19......1.0.....5......25......250.....10.... ref SDS N7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260445 -          1.53  170404   80   80     16.5   18......1.5.....5......25......200.....10.... ref SDS N1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260446 -          1.53  170221   80   80     15     18......2.0.....5......25......200......5.... ref SDS M4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260447 -          0.80  170106   80   80     16.5   18......2.0.....5......25......200......5.... ref SDS L8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260448 -          0.23  161213   80   80     15     18......3.0.....5......25......200......5.... ref SDS L2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260449 -          0.20  161206   80   80     11     16.5....1.0.....5......25......200......5.... ref SDS K8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260450 -          0.27  161130   80   80     11     15......0.0.....5......25......200......5.... ref SDS K5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260451 -          0.23  161122   80   80      6     12......0.0.....5......25......200......5.... ref SDS K3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260452 -          1.40  161115   42   80     10     10......0.0.....5......25......200......5.... ref SDS J9 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260453 -          0.83  161004   26   80     11     15......5.0.....5......25......200......5.... ref SDS J3 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260454 -     *1   0.80  160909   80    0     10     15......5.0.....5......25......200......5.... ref SDS I9 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260455 -          2     160816   11   40      9.5   10......5.0.....4......50......150......5.... ref SDS I3 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260456 -          3     160617   10   40      9.5   15......5.0.....6......50......250......5.... ref SDS H0 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260457 -     *2   3     160315   15   40      9.5   15......3.0.....5......25......250......5.... ref SDS G8 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260458 -          8     151204   32   20     10     15......5.0.....5......25......200......5.... ref SDS F4 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260459 -     *3   6     150421   41          16.5   18......3.0.....4......50......250......5.... ref SDS D4 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260460 -          6     141107   37          15     18......4.0.....5......50......150......5.... ref SDS C5 E54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260461 -          6     140509   24          16.5   18..............5......50......200......5.... ref SDS B5 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260462 -     *4   7     131115   24          16.5   18......2.0.....4......50......200......5.... ref SDS A6 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260463 -          3     130416   38          18     18......2.0.....5......50......250......5.... ref SDS A0 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260464 -          4     130110   39          15     18......3.0.....4......50......100......5.... ref SDS 95 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260465 -     *5   6     120925   38          15     18......4.0.....5......50......200......5.... ref SDS 87 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260466 -     *6   4     120322   27          16.5   18..............4......50......150......5.... ref SDS 84 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260467 -     *7   3     111115   76          16.5   18..............4......50......200......5.... ref SDS 81 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260468 -          4     110819   80          15     16.5....2.5.....5......50......200......5.... ref SDS 80 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260469 -          2     110429   80          13     16.5....3.5.....5..............200......5.... ref SDS 75 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260470 -          2     110218   80          11     14......2.0.....4......50......150......5.... ref SDS 71 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260471 -          4     101210   40          11     14......................................5.... ref SDS 66 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260472 -          6     100827    4          11     15..............5......50......250......5.... ref SDS 55 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260473 -          3     100305    0          11     15..............5......50......250......5.... ref SDS 48 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260474 -          -     091216               Heller Myotomy Fundoplication................. ref SDS 36 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260476 -         ..
260477 -     ** Dates are from case study on exercise, diet, vitals and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260478 -        medication, shown on 160101, ref SDS G1 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260479 -        previously on 140101. ref SDS B0 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260480 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260481 -     *1 On 160911 paused Pantoprazole to reduce dehydration through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260482 -        frequent urination until after Half Dome, and resumed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260483 -        160920.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260484 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260485 -     *2 On 151210 begin Omeprazole 20 mg every other day. ref SDS B0 E64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260486 -        Resumed Omeprazole 20 mg on 160323. ref SDS G1 RSXR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260488 -         ..
260489 -        On 150924 hospitalized hematoma debridement; begin Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260490 -        20 mg per day. ref SDS B0 JT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260491 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260492 -     *3 On 150920 about 5 attacks convulsions, nausea not taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260493 -        Omeprazole - took 40 mg. ref SDS B0 656M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260494 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260495 -     *4 On 131115 Doctor Lee prescribed Omeprazole 40 mg 1 month then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260496 -        20 mg for next 5 months. ref SDS A6 ZY5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260498 -         ..
260499 -     *5 On 130106, 4 days before EGD on 130110, reduced Omeprazole to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260500 -        20 mg per day, shown in case study on 120101 0900, ref SDS 83                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260501 -        AD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260503 -     *6 On 120907 Doctor Egan research found Omeprazole increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260504 -        blood pressure, sensed possible correlation patient sudden                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260505 -        rise in blood pressure, recommended reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260506 -        to 20 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260508 -     *7 On 11115 Doctor Lee prescribed continue PPM 80 mg; on 111201,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260509 -        patient reduced dose to 20 mg on record of rising blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260510 -        pressure despite increased hiking; research indicated PPI may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260511 -        elevate blood pressure, see case study 101010 0744, ref SDS 57 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260512 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260513 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260515 -  ..
260516 - Conscious Sedation Reduced Dose Applied for 12 Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260517 - 
260518 - Follow up ref SDS X6 714N, ref SDS X0 714N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260520 - Nursing Procedural Sedation & Analgesia Flow Sheet Record Page 1 shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260521 - versed 2 ML.  Since procedure only took 12 minutes, ref SDS 0 Q65I,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260522 - the doctor was able to minimize exposure to versed, which previously                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260523 - caused stroke symptoms with 6 ml, as occurred on 160617 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260524 - ref SDS H0 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260526 -               ..
260527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260529 -  ..
260530 - No post procedure side effects as occurred previously on 161213 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260531 - ref SDS L2 R74J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260533 -  ..
260534 - Seem sleepy though even hours after the procedure using 3 ml versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260535 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260536 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260538 -  ..
260539 - Ulceration on Esophagus Above LESV Significantly Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260540 - 
260541 - Follow up ref SDS X6 RZ3G, ref SDS X0 RZ3G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260543 - Doctor Lee reported this morning that EGD procedure found that both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260544 - ulcerations on the side of esophagus above LESV continue to be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260545 - completely resolved, reported following EGD on 190917 0730.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260546 - ref SDS V9 RZ3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260548 -  ..
260549 - As a result, he omitted Triamcinalone again today, and maintained                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260550 - medication regimen taking Pantoprozole everyday - see case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260551 - above. ref SDS W0 YR4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260553 -  ..
260554 - Doctor Lee did not have time to present pictures showing improved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260555 - condition with reduced ulceration of LESV, following EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260556 - procedure today, per above. ref SDS W0 GD5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260558 -  ..
260559 - Pictures from procedure were later received on 191209, and are at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260560 - bottom of the file...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260561 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260562 -              F:\05\00003\SM\CC\AGMJ\20191112-083000\WELCH12092019.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260564 -  ..
260565 - Decided to continue pentoprazole everyday before dinner for next 8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260566 - weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260568 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260569 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260570 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260572 -  ..
260573 - Schedule Next Procedure and Post Procedure Review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260574 - 
260575 - Follow up ref SDS X6 XF6X, ref SDS X0 XF6X.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260576 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260577 - Next procedure is scheduled on 200707 0930, ordered by Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260578 - 200310 0830. ref SDS X6 W44N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260580 -  ..
260581 - Since LESV seems to have contracted back to 19 mm during this 2.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260582 - month cycle, Doctor Lee considered scheduling follow up procedures on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260583 - 3 month cycles.  Ultimately decided to schedule on 2 month cycles, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260584 - evaluate after each procedure possibly skipping a scheduled procedure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260585 - if things go really well.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260587 -  ..
260588 - Continuing schedule for EGD is...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260589 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260590 -        Jul 07 2020   0930   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260591 -        Sep 08 2020   0930   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260592 -        Nov 03 2020   0830   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260593 -        Jan 05 2020   0830   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260594 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260595 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260596 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260597 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260598 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260599 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2606 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 X6 Q05K, ref SDS X0 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 200401 Kathy went to ROI at Sacramento VA Mather Field, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270421 - submitted VA Form 10-5345a...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270422 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270423 -            INDIVIDUALS' REQUEST FOR A COPY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270424 -            OF THEIR OWN HEALTH INFORMATION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270426 -  ..
270427 - Request is for information to be delivered to the individual...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270428 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270429 -        x  CD-ROM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270431 -  ..
270432 - For some reason, ROI mailed progress notes printed on paper instead                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270433 - of a CD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270435 -  ..
270436 - Stored Progess Notes for procedure on 190813 at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270437 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270438 -              F:\05\00003\SM\CC\AGMJ\20200110-083000\WELCH01242020.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270440 -  ..
270441 - This file includes photographs taken during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270443 -         ..
270444 -    1.  LOCAL TITLE: EGD Procedure Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270445 -        STANDARD TITLE: GASTROENTEROLOGY DIAGNOSTIC STUDY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270446 -        DATE OF NOTE: MAR 10, 2020@17:45:35 ENTRY DATE: MAR 10, 2020@17:45:35                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270447 -        AUTHOR: CLINICAL,DEVICE PRO  EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270448 -        URGENCY:           STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270449 -        *** EGD Procedure Report Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270450 -        ** DOCUMENT IN VISTA IMAGING **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270451 -        SEE FULL REPORT IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270452 -        SIGNATURE NOT REQUIRED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270453 -        SEE SIGNATURE IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270454 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270455 -        ** (PENTAX EGD)  AUTO-INSTRUMENT DIAGNOSIS **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270457 -         ..
270458 -    2.  Procedure: EGD  UPPER ENDOSCOPY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270460 -         ..
270461 -    3.  PENTAX INSTRUMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270462 -        10535 Hospital Way Mather CA, 95655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270464 -         ..
270465 -    4.  EGD PROCEDURE REPORT     EXAM DATE: 03/10/2020                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270469 -        VISIT #:  3200310062744                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270471 -         ..
270472 -    5.  ATTENDING:     Randall Lee, MD STATUS:     outpatient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270473 -        ASSISTING MD:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270474 -        ASSISTANT:  Edward Harris, Tech and Gracie Hall, RN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270476 -         ..
270477 -    6.  INDICATIONS: The patient is a 74 yr old male here for an EGD due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270478 -        PROCEDURE PERFORMED:   EGD diagnostic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270479 -        MEDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270480 -        TOPICAL ANESTHETIC:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270482 -         ..
270483 -    7.  CONSENT:  The risks, benefits, and alternatives to this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270484 -        procedure including but not limited to the risks of bleeding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270485 -        and bowel perforation were explained to the patient.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270486 -        patient understood and provided written informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270488 -         ..
270489 -    8.  DESCRIPTION OF PROCEDURE:  In the Sacramento VA GI Endoscopy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270490 -        Unit,  Informed consent was verified, confirmed and timeout                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270491 -        was performed. The patient was placed in left lateral                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270492 -        decubitus position.  Oxygen was administered. Continuous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270493 -        oximetric and hemodynamic monitoring was initiated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270494 -        Intravenous sedation was administered in divided doses.  After                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270495 -        a bite block was placed in the patient's mouth,  the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270496 -        GIF-1TH190-2400353 videoscope was introduced under direct                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270497 -        vision through the mouth and advanced to the   .      The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270498 -        stomach and esophagus were decompressed, and the gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270499 -        removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270501 -         ..
270502 -    9.  ADVERSE EVENTS:     There were no complications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270503 -        IMPRESSIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270504 -        RECOMMENDATIONS:    EGD & dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270506 -         ..
270507 -        Versed 3mg.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270508 -        fentanyl 150mcg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270509 -        Benadryl 50mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270510 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270511 -        start 0926                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270512 -        end 0938                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270513 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270514 -        1.  Proximal and mid esophageal body dilated and aperistaltic,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270515 -            with accumulation of saliva within the esophageal body that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270516 -            required irrigation and suctioning to achieve a clear view                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270517 -            of the esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270519 -             ..
270520 -        2.  Tattoo site in the esophageal body at about 31 cm again                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270521 -            noted without evidence of mass effect or ulceration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270523 -             ..
270524 -        3.  Distal esophageal mucosal defects, shallow, at prior sites                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270525 -            of ulcerations.  No evidence of active ulceration,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270526 -            inflammation or erosion.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270528 -             ..
270529 -        4.  Esophageal stricture located at the GE junction at 38-39                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270530 -            cm, estimated diameter of approximately 19 mm.  This was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270531 -            balloon dilated to 20 mm, as evidenced by minimal mucosal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270532 -            trauma only after balloon dilation from 19-20mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270534 -             ..
270535 -        5.  Diaphragm located at 40 cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270537 -             ..
270538 -        6.  Normal-appearing gastric mucosa in the fundus and body.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270539 -            Gastric fundus appearance consistent with prior history of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270540 -            fundoplication with relaxation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270542 -             ..
270543 -        7.  Gastric mucosa in the antrum with mild patchy erythema but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270544 -            no ulceration, erosion, or mass effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270546 -             ..
270547 -        8.  Normal pylorus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270549 -             ..
270550 -        9.  Normal duodenum to D3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270552 -         ..
270553 -        Very minor reduction in GE junction lumen since last dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270554 -        of January 2020.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270555 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270556 -        continue current anti-acid reflux therapies.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270557 -        repeat EGD & dilation in 2 months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270559 -         ..
270560 -        REPEAT EXAM:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270561 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270562 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270563 -        ___________________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270564 -        Randall Lee, MD eSigned:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270565 -        eSigned: Randall Lee, MD 3/10/2020 17:45:30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270566 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270568 -        cc:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270569 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270570 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270571 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270572 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270573 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270574 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270575 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270576 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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270578 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270579 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270580 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270581 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270582 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270583 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270584 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270585 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2706 -