CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2503 -    ..
2504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
2505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250501 - Follow up ref SDS K2 0000. ref SDS J7 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250508 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250509 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250511 -  ..
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 19 NX6M  Surgery team will coordinate with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251016 - anesthesia team to provide swallowing relief during heart surgery to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251017 - prevent choking. ref SDS 19 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 20 JF9K  While being prepared with IVs for surgery, patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251023 - assists anesthesia find VA records on achalasia, ref SDS 20 2W4K;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251024 - Doctor Brezenski makes plans for patient care and safety so that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251025 - achalasia does not risk death during heart surgery. ref SDS 20 GX4J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251027 -  ..
251028 - On 091022 cabg x4 cardiothoracic surgery San Francisco Medical Center.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251029 - ref SDS 20 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 21 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 21 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 21 03GF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251051 -  ..
251052 - On 091216 Heller Myotomy surgery at San Francisco VA Medical Center to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251053 - recover from achalasia. 091216 0600, ref SDS 22 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 23 485W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251068 -  ..
251069 - On 100305 meeting at GI Clinic in Martinez, EGD procedure dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251070 - from 11 to 15 mm. ref SDS 24 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251072 -  ..
251073 - On 100827 meeting at GI Clinic in Martinez, EGD procedure dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251074 - from 11 to 15 mm. ref SDS 25 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251076 -  ..
251077 - On 101210 EGD procedure dilated esophageal sphincter valve (LESV)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251078 - without sedation, ref SDS 29 BE7K - dilated LESV again from 11 to 14                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251079 - mm. ref SDS 29 BF6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251081 -  ..
251082 - On 101216 1021 letter commends medical team for excellent work, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251083 - confirms schedule next EGD on 110218 0730. ref SDS 31 K35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251085 -  ..
251086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251087 - anesthesia with Fentanyl. ref SDS 33 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 33 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 35                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 35 U23I, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251097 - triamcinolone injections were continued. ref SDS 35 SS5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251099 -  ..
251100 - On 110607 1414 visited GI Department, ref SDS 37 HC5H, and Charlene                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251101 - reported a computer mistakes requires scheduling next EGD dilation on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251102 - 110819 0830. ref SDS 37 N642  Requested meeting with Doctor Lee to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251103 - review pending action items. ref SDS 37 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 38 J978, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251110 - triamcinolone injections were continued. ref SDS 38 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 39 IR57; for some reason triamcinolone injections to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251116 - resist contraction of LESV was not performed. ref SDS 39 IS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251118 -  ..
251119 - On 111201 0928 seems to be 10% increase in blood pressure the past                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251120 - month, ref SDS 40 ZM5H, beginning on 111030, shown by case study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251121 - 101010 0744. ref SDS 27 UT6K  Case study reports Omeprazole paused on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251122 - 111201. ref SDS 27 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 42 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 42 UI9H  LESV dilated from 16.5 - 18 mm. ref SDS 42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251133 - 516N  Triamcinolone injections to resist contraction of LESV was not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251134 - performed. ref SDS 42 5179                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251136 -  ..
251137 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251138 - business unit; reported patient history. ref SDS 44 RG9K  Scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251139 - EGD and dilation procedure for 1300; returned and performed procedure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251140 - ref SDS 44 TB4J; dilated from 15 mm to 18 mm. ref SDS 44 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251141 - Swallowing and vomitting problems increased after omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251142 - triamcinolone steriod injections to resist contraction of LESV after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251143 - dilation, ref SDS 44 TZ4M; therefore, injections were resumed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251144 - complement dilation to enable and maintain effective swallowing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251145 - ref SDS 44 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 45 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251152 -  ..
251153 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251154 - remained at 18 MM, ref SDS 46 CO5N, same as dialated 4 months earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251155 - on 130110 0900. ref SDS 45 Q333  Report CT test on 130117, shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251156 - esophagus fully recovered from severe distortions caused by achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251157 - 8 years earlier. ref SDS 46 MT6F  Doctor Lee injected steriod again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251158 - maintain swallowing. ref SDS 46 F38G  Prescribed reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251159 - to 1 pill per day. ref SDS 46 R74M  Scheduled next EDG dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251160 - months, instead of 3. ref SDS 46 6P6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251162 -  ..
251163 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251164 - to 18 mm. ref SDS 47 CO5N  Triamcinolone steriod injected again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251165 - maintain improved swallowing. ref SDS 47 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 47 R74M  Biopsies taken. ref SDS 47 3N8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251169 -  ..
251170 - On 131121 1604 ordered refill of Omeprazole to aid digestion.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251171 - is 1 refill remaining. ref SDS 48 YS4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251173 -  ..
251174 - On 131205 1443 received order for Omeprazole prescription placed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251175 - 131121. ref SDS 49 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251177 -  ..
251178 - On 140318 1043 received letter cancelling meeting scheduled for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251179 - EGD/Dilation procedure on 140425 1000, ref SDS 51 935L; a second                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251180 - letter scheduled prodedure on 140509 0900. ref SDS 51 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 52                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251185 - 4P5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251187 -  ..
251188 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251189 - center in Sacramento, Mather. ref SDS 53 K37G  Pre-op preperation went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251190 - well - IV setup on first stick. ref SDS 53 EP75  Doctor ordered refills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251191 - for Omeprazole. ref SDS 53 AW5O  Doctor patient partnership continues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251192 - to progress with doctor reading up on patient history to be prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251193 - for effective meeting. ref SDS 53 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 53 0N6I  Reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251196 - swallowing and vomitting problems reduced past 6 months with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251197 - triamcinolone steriod injections to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251198 - ref SDS 53 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 53 5H5J, scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251201 - next EGD dilation in 6 months since this worked well the past 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251202 - with triamcinolone steriod injections. ref SDS 53 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 53 I167  Progress notes report small tearing of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251206 - LESV during dilation procedure. ref SDS 53 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251208 -  ..
251209 - On 140718 1017 planning for notifying VA to update current fill date                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251210 - for Omeprazole. ref SDS 54 U88L  Kathy visited VA in Sacramento, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251211 - requested changing refill date for Omeprazole to 140718. ref SDS 54                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
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 54 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 55 W83K, based on history rising vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251220 - swallowing problems, shown in patient history case study on 120101,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251221 - beginning 140712. ref SDS 41 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 56 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 57 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 58 K37G  Submit record showing normal swallowing occurs longer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251239 - with triamcinolone steriod injection to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251240 - ref SDS 58 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 58 3U66  Notified results of Half Dome hike.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251243 - ref SDS 58 3U6Y                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251245 -  ..
251246 - On 141107 0800 EGD dilation procedure - setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251247 - sedation required 3 sticks. ref SDS 59 5W5I  Meeting Doctor Lee guided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251248 - by agenda facilitated collaboration through doctor patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251249 - partnership. ref SDS 59 VV6N  Doctor explained increased difficulty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251250 - swallowing due to experiment omitting triamcinalone steriod injection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251251 - on prior procedure, ref SDS 59 4U8I, shown by LESV contracting back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251252 - from 15 mm. ref SDS 59 T55I  Progress Notes report finding ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251253 - and hiatal hernia. ref SDS 59 MG6N  Photographs seem to show                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251254 - significantly different condition of fundoplication from a year                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251255 - earlier. ref SDS 59 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 60 0M6I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251261 - Lee advised that increased orange juice consumption aids digestion,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251262 - and presents no health risks. ref SDS 60 YF5M  Scheduled next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251263 - dilation procedure on 150421 1300. ref SDS 60 PS4O  Fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251264 - failure increases acid burn that caused ulceration with hiatal hernia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251265 - with increased recurrance achalasia. ref SDS 60 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 60 JQ5J  Doctor Lee completed Progress Notes for EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251269 - on 141107. ref SDS 60 PS53  Doctor Lee will recommend Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251270 - order CT test to evaluate recurrance achalasia due to failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251271 - fundoplication. ref SDS 60 TH5M  This test can include coronary CTA to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251272 - evaluate regression atherosclerosis. ref SDS 60 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 61 0M6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251278 -  ..
251279 - On 150421 Met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251280 - (Mather). ref SDS 62 K37G  No difficulties setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251281 - sedation. ref SDS 62 5W5I  Reported pain level 2 right knee MCL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251282 - ref SDS 62 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 62 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 62 P55L, and shown by EGD dilation LESV from 16.5 mm back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251288 - 18 mm. ref SDS 62 HU42  Progress Notes report findings of hiatal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251289 - hernia. ref SDS 62 QD6O  Impression today that ulceration has subsided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251290 - to mere errosions seems promising. ref SDS 62 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 64 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 65 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 66 3E4I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251309 - Stewart explained redo Dor Fundoplication required for "repairing"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251310 - original surgery, presents high risk of collateral damage. ref SDS 66                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
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 66 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 67 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 68 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 69                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
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 69 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 70 5G8T  As a result, Pharmacy VA Medical Center San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251350 - entered new prescription for (PPI) Omeprazole 20 mg. ref SDS 70 FK66                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251352 -  ..
251353 - On 150925 0336 VA scheduled next meeting for EGD dilation on 151204                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251354 - 0800. ref SDS 70 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 71 NV5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251362 -  ..
251363 - On 151012 1151 VA Internet Pharmacy lists updated Omeprazole 20 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251364 - prescription. ref SDS 63 0C5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251366 -  ..
251367 - On 151204 0800 met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251368 - (Mather); initial administration went well. ref SDS 72 GD4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251369 - Preparation for the procedure was professional; no difficulties                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251370 - setting IV for conscious sedation today. ref SDS 72 544G  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251371 - reported not receiving letter with agenda for the meeting today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251372 - submitted on 151201. ref SDS 72 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 72 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 72 G53K  Performing EGD dilation procedure went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251380 - smoothly, with no difficulties. ref SDS 72 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 72 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 73 J56O  Doctor prescribed adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251392 - Famotidine an H2 blocker taken once a day to compliment Omeprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251393 - ref SDS 73 YL3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251395 -  ..
251396 - On 160325 0900 Diffuculty swallowing this cycle began about 1 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251397 - after prior EGD dilation on 151204. ref SDS 75 P55L  Reported using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251398 - baking soda to relieve reflux that prevents ulceration LESV; this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251399 - reduced Omeprazole in order to avoid dehydration. ref SDS 75 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 75 PXXY  EGD dilation procedure went smoothly, with no reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251404 - of difficulties. ref SDS 75 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 75 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 83 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 85 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 99 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 A0 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 A6 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 K2 E84I, ref SDS J7 E84I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251806 - EGD treatment with Doctor Lee today, was scheduled for 4 months by the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251807 - doctor after the EGD on 240116 0830. ref SDS J7 XF6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251809 -  ..
251810 - Doctor Lee has been doing EGD procedures every 6 months, Schedule was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251811 - updated by Jessica extending procedures to Jan of 2022, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251812 - 201106 0930, ref SDS F9 D45N  After procedure on 210305, the doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251813 - said patient is doing so well that next procedure would be in 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251814 - on 210905, reported on 210305 0930. ref SDS G6 PJ5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251816 -  ..
251817 - However, after the last EGD, Doctor Lee changed the duration to 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251818 - months, reported on 240116 0830. ref SDS J7 XF6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251819 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251821 -  ..
251822 - Applied EGD pre-proc requirements for NPO after midnight, from letter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251823 - on 101015 1547. ref SDS 28 4J9L  Last food was at......                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251824 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251825 -                         230302 1830                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251827 -  ..
251828 - Yesterday, drove to Sacramento from Concord, and stayed at Amy's house                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251829 - in Elk Grove about 20 miles from VAMC Sacramento.  Kathy died on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251830 - 230716 0741. ref SDS J2 GF7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251832 -  ..
251833 - This morning, Amy drove us to the hospital.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251834 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251835 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251837 -  ..
2519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2521 - 1238                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252201 - Arrived at VAMC Sacramento.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252203 -  ..
252204 - Vincent did check-in to GI Department at the customer counter.  He is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252205 - new since prior treatment visit on 230303 0830. ref SDS I9 1X6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252206 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252208 -  ..
2523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2525 - 1256                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252601 - Vincent did vitals.  He took us into the procedure area, without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252602 - doing vitals in the small room adjacent to the checkin counter,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252603 - because processing is running late today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252605 -  ..
252606 - Vitals were taken and found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252608 -            Weight.................. 172                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252609 -            BP...................... 154 87                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252610 -            HR (pulse).............. 52                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252611 -            Oxygen.................. 98%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252612 -            Temp.................... 96.3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252613 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252615 -  ..
252616 - Amy's cell phone for designated driver...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252620 -  ..
252621 - Amy signed the discharge form affirming she will be designated driver,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252622 - and responsible to facilitate no driving for 24 hours, and following                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252623 - up Kathy passing away on 230716 0741. ref SDS J2 0T5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252624 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252625 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252627 -  ..
2527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2529 - 1300                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253001 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253002 - 
253003 - Follow up ref SDS K2 Y68O, ref SDS J7 Y68O.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253004 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253005 - No objections nor concerns today, as occurred previously on 161115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253006 - 0800, ref SDS 81 WA5I, and again on 161130 1038. ref SDS 84 EP75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253008 -  ..
253009 - Did not see Jennifer to say hello today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253011 -  ..
253012 - In the GI Clinic, Grace directed me to a gurney.  She helped with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253013 - patient gown and setup on the gurney.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253015 -  ..
253016 - Nursing staff - everyone said hello...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253017 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253018 -           Danise............. now working part time only on Tuesdays                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253019 -           Shawna............. She set IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253020 -           Gracie............. She was recovery nurse today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253021 -           Grace.............. She helped with gown                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253022 -           Mimi............... entered record patient history                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253023 -           Rodalie............ She is charge of the nurse team now                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253024 -           Hazel.............. Said hello                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253025 -           Rachel............. She has not done Whitney recently, looking forward to hiking Half Dome but nothing scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253026 -           Lara............... not at work today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253027 -           Dan................ not at work today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253028 -           Frank.............. Frank helped in recovery today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253029 -           Tanya.............. did not see him                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253030 -           Vincent............ new nurse was in OR giving versed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253031 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253033 -  ..
253034 - Said hello to Danise today, since she only works part time on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253035 - Tuesdays.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253037 -  ..
253038 - Gracie was busy with other patients.  She came by and said hello.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253040 -  ..
253041 - Vincent entered patient history in the computer.  Most information                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253042 - entered today, for patient identification and medical history is the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253043 - same.  Advised had cardiac ablation on 240611 0930. ref SDS K4 RX9J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253045 -  ..
253046 - Vincent set catheter IV for sedation.  He asked for best location to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253047 - get a good vein.  Explained inner right elbow right side vein has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253048 - worked well for recent blood draws and IV.  Did not do 10 pushups with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253049 - feet on chair to improve blood flow about an hour before arriving at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253050 - hospital.  Veins develop adhesions (scar tissue) that take time to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253051 - heal, and prevent blood flow into the IV needle.  This morning ran hot                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253052 - water on right forearm in the shower to dilate veins, which helped to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253053 - get blood flow on 1st stick today.  Vincent used this location at inner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253054 - right side and below elbow - pain level 4, but only momentary.  It was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253055 - successful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253057 -  ..
253058 - Case study on sticks required to set catheter is reported on 110429                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253059 - 1230. ref SDS 36 UO3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253060 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253062 -  ..
253063 - Rachael - did not see her today.  She may have been in a procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253064 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253065 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253066 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253067 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253069 -  ..
2531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2533 - 1331                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253401 - Meeting Doctor Lee and Consent for Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253402 - 
253403 - Follow up ref SDS K2 GG6G, ref SDS J7 GG6G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253405 -  ..
253406 - Doctor Lee asked questions on patient history to verify ready for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253407 - procedure, e.g., no allergies, and NPO after midnight to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253408 - conflicts with anesthesia; no health problems, e.g., no diabetes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253409 - alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253411 -  ..
253412 - Doctor Lee asked about medication protocol?  Reported protocol he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253413 - prescribed after EGD on 190416 1000. ref SDS B5 JK6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253415 -  ..
253416 - This morning he confirmed the following prescription...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253417 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253418 -    **  Famotidine................0700.... 2 40mg pills in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253419 -        Simethicone....................... 1 80 mg pill as needed for bloating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253421 -         ..
253422 -        Hiking - most everyday taken 30 minutes before start hikes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253423 -        Glucosamine Chondroitin...........    80 ml (couple swallows)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253424 -        Oxycodone......................... paused                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253425 -        Tramadol.......................... paused                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253426 -        Gabapentan........................ paused                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253427 -        Diclofenac gel topical feet....... paused                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253428 -        magnesium.........................   350 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253429 -        Naproxen NSAID.................... paused                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253431 -         ..
253432 -        CoQ10............................. before and during hiking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253433 -        Chia seeds........................ before and during hiking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253435 -         ..
253436 -    **  Pantoprazole..............1700.... 1 40mg pill 30 min before dinner every day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253437 -        Atorvastatin..............1830.... 1 10mg pill every other day hour after dinner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253438 -        Ezetimibe.................1830.... 1 10mg pill every other day hour after dinner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253439 -        Calcium Carb (Tums).......2200.... 2 500mg pills 30 min after Mylanta                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253440 -        Famotidine................2230.... 2 40mg pills before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253441 -        Mylanta...................2300.... 40 ml OA 2000 - 1 hour after statins                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253443 -  ..
253444 - During the meeting for the last EGD, Doctor Lee recommended taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253445 - Mylanta last at night to coat throat and LEAV, protecting against                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253446 - achalasia, reported on 240507 0930. ref SDS K2 K54L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253447 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253449 -  ..
253450 - Nutrition taken during hikes every 5 - 10 miles...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253451 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253452 -        softdrink carbonated.............. hydration and swallowing meds and nutrition                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253453 -        magnesium......................... for energy and resolve inflammation caused by injuries, e.g., feet and knees                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253454 -        peanut butter..................... for protein and magnesium - energy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253455 -        avocado........................... for HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253456 -        margarine......................... help swallow peanut butter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253457 -        Chia seeds........................ for electrolytes and energy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253458 -        CoQ10............................. aids heart and liver - big energy boost for hills and HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253459 -        electrolytes...................... replace from sweating while hiking in elevated temperatures                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253460 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253462 -  ..
253463 - Need new prescriptions for...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253464 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253465 -        Pantoprazole.. new prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253466 -        Famotidine.... new prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253467 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253468 -            [...below on 240910 1300 at 1150 after the EDG procedure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253469 -            meeting with Doctor Lee he advised that new prescriptions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253470 -            were entered for Pantoprazple and Famotidine. ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253471 -            KH6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253473 -             ..
253474 -            [On 240916 1324 received refills for Pantoprazole and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253475 -            Famotidine. ref SDS L0 LQ5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253476 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253477 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253478 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253479 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253481 -  ..
253482 - Lab Test HDL Treating Atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253483 - 
253484 - Follow up ref SDS K2 IF8I, ref SDS J7 IF8I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253485 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253486 - Did not order lab today, to test lipids - HDL in accordance with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253487 - recommendations to test Acetaminophen pain medication, reported in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253488 - progress notes on 240507 0930. ref SDS K2 F76G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253490 -  ..
253491 - Evaluate frequent urination - a1c lab for diabetes was negative on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253492 - 240212 0937. ref SDS J8 2P6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253494 -  ..
253495 - Frequent urination seems calmed lately, see study. ref SDS C2 F29N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253496 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253497 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253499 -  ..
253500 - Paroxysmal Atrial Fibrillation Treated Ablation Pulmonary Vein Isolation on 200430                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253501 - Right Atrial Flutter Treated Ablation on 200511                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253502 - Vision Diminished Fatigue Sleepy Taking Metoprolol Treatment PAF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253503 - 
253504 - Follow up ref SDS K2 XN5F, ref SDS J7 XN5F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253506 - On 200430 0700 left atrial ablation performed by Doctor Pellegrini.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253507 - ref SDS C9 9C9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253509 -  ..
253510 - On 200511 0546 at 1342 went to ASU for preparation to do ablation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253511 - ref SDS D2 244I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253513 -  ..
253514 - On 200527 0930 telecon meeting with Doctor Pellegrini advised ablation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253515 - procedures successfully treated atrial fibrillation and atrial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253516 - flutter. ref SDS D3 JJ6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253518 -  ..
253519 - On 201210 0700 3rd cardiac ablation and 2nd for right atrial to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253520 - resolve recurrent atrial flutter. ref SDS G3 4H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253522 -  ..
253523 - On 211115 0900 4th cardiac ablation and 2nd for left and right atrials                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253524 - to resolve recurrent atrial fibrillation. ref SDS H3 XV7S                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253526 -  ..
253527 - On 231214 0630 5th cardiac ablation for AFL atypical in left atrial.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253528 - ref SDS J6 VZ5L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253530 -  ..
253531 - On 240611 0930 6th cardiac ablation for AFL atypical in left atrial,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253532 - making corrections to 5th ablation. ref SDS K4 P85O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253534 -  ..
253535 - Had 26 AFL episodes last year, listed on 200101 0701. ref SDS C2 H54I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253536 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253537 -        Digestive problems:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253538 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253539 -        "...patients have trouble moving food through their GI tract                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253540 -        after ablation.  Symptoms include reflux, feeling bloated, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253541 -        intolerance of big meals, while signs may include distention of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253542 -        the abdomen.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253544 -  ..
253545 - See research on 200508 0916. ref SDS D1 OS49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253548 -  ..
253549 - Recovery from Achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253550 - Swallowing Has Been Effective Past 4 Months Until 1 Month Ago                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253551 - 
253552 - Follow up ref SDS K2 VV6N, ref SDS J7 VV6N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253554 -  ..
253555 - Eating regimen including carbonated drinks with meals to clear                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253556 - esophagus is shown in case study of daily diet, medication, exercise                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253557 - and vitals, reported on 220101 0635. ref SDS H4 PUSQ                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253559 -  ..
253560 - Reviewed eating practice - seem to have recovered from former                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253561 - difficulties swallowing due to achalasia.  Esophagus has regained lost                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253562 - strength; now able to push food through Lower esophagual sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253563 - valve (LESV).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253565 -  ..
253566 - Vomiting the past cycle...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253568 -          no episodes recorded                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253570 -  ..
253571 - Drinking carbonated (Coca Cola mixed with lemon and orange juice)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253572 - cleared throat.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253574 -  ..
253575 - Saliva bubbles clogging LESV seems increased past month from reflux.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253577 -  ..
253578 - Voice fades significantly at times, likely related to buildup of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253579 - saliva in esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253581 -  ..
253582 - Doctor Lee noted voice this morning is weaker than normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253584 -  ..
253585 - Burping stable and reduced compared to years past.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253587 -  ..
253588 - Barium swallow test seems to show esophagus recovered, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253589 - 211021 0715. ref SDS H2 SL57  Aligns with experience having no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253590 - vomiting nor other swallowing deficits past year.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253591 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253592 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253594 -  ..
2536 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2538 - 1339                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2539 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253901 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253902 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253903 - 
253904 - Follow up ref SDS K2 KT9M, ref SDS J7 KT9M.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253906 -  ..
253907 - Doctor Lee presented a digital tablet for signature to consent for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253908 - procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253910 -  ..
253911 - Noted that signature is entered on completely black screen, required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253912 - without reading online documents.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253914 -  ..
253915 - Advised that signature is based on following understandings...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253916 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253917 -    1.  CT on 230831 reported...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253918 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253919 -        "Mild apparent distal esophageal wall thickening.  Correlate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253920 -        for any esophagitis." 230831 0800, ref SDS J3 N13S                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253922 -  ..
253923 - Is this evaluated with normal examination during EGD procedure?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253925 -  ..
253926 - Actually, this was not discussed today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253927 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253929 -         ..
253930 -    2.  Bloating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253931 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253932 -        Past few months, seems like stomach pressure/bloating is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253933 -        occurring more often during hikes, so taking more Simethicone.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253935 -         ..
253936 -        Bloating makes bending down to tie shoes difficult???                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253938 -         ..
253939 -        Can medications drive bloating, per above? ref SDS 0 PF3H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253941 -         ..
253942 -        This has been reported to Doctor Pellegrini in Cardiology on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253943 -        240623 0941. ref SDS K5 XP5H and to Lauren in Primary Care, see                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253944 -        letter to Lauren on 240703 1027. ref SDS K6 ZP7I  Most                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253945 -        recently, bloating issue was reviewed by Doctor Pellegrini last                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253946 -        week on 240905 0830. ref SDS K7 HL8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253948 -         ..
253949 -        Doctor Lee seemed to say, he read Doctor Pellegrini's progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253950 -        notes on bloating.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253951 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253952 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253953 -            On 240910 1300 Doctor Lee's progress notes report bloating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253954 -            issue; do not indicate any treatment. ref SDS 0 E89K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253956 -         ..
253957 -        Research found Pantoprazole can cause bloating and stomach pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253958 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253959 -               See Side Effects (Incidence not known)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253960 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253961 -                     https://www.mayoclinic.org/drugs-supplements/pantoprazole-oral-route/side-effects/drg-20071434?p=1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253962 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253963 -                   On 220811 0728 letter to Danise for Doctor Lee to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253964 -                   investigate ischemic colitis causing bloating.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253965 -                   ref SDS I4 KR86                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253967 -         ..
253968 -        Pantoprazole can cause blurred vision.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253970 -         ..
253971 -        Actually, looks like Famotidine also causes bloating.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253972 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253973 -                     https://www.netdoctor.co.uk/medicines/digestion/a7327/famotidine/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253974 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253976 -         ..
253977 -    3.  Blood Pressure Increased after Taking Pantoprazole 10 years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253978 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253979 -        On 120322 1030 notified Doctor Lee during meeting at VA changed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253980 -        dose for Omeprazole to reduce sudden increase from low to high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253981 -        blood pressure. ref SDS 43 UH5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253983 -         ..
253984 -        Previously, research also indicated omeprazole can cause high blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253985 -        pressure, reported on 101218 1642. ref SDS 32 1J5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253987 -         ..
253988 -        Past 6 - 12 months, seems like blood pressure has been higher                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253989 -        than expected for hiking 20 miles per day.  Had forgotten                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253990 -        prior research on Omeprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253991 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253993 -         ..
253994 -        An article says...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253996 -             ..
253997 -            Research shows proton pump inhibitors may cause cardiovascular problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253998 -            
253999 -            Follow up ref SDS K2 GF6I, ref SDS J7 GF6I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254000 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254001 -              https://www.news-medical.net/news/20130711/Research-shows-proton-pump-inhibitors-may-cause-cardiovascular-problems.aspx                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254003 -             ..
254004 -            In human tissue and mouse models, the researchers found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254005 -            PPIs caused the constriction of blood vessels. If taken                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254006 -            regularly, PPIs could lead to a variety of cardiovascular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254007 -            problems over time, including hypertension and a weakened                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254008 -            heart. In the paper, the scientists call for a broad,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254009 -            large-scale study to determine whether PPIs are dangerous.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254011 -         ..
254012 -    4.  Ischemic colitis - see discussion above. ref SDS K2 SS6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254014 -         ..
254015 -        Need new prescriptions for medications, listed in record of VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254016 -        Pharmacy on 230210 0914. ref SDS I7 6H6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254018 -         ..
254019 -    5.  Pantoprazole - there is 1 refill available, so will likely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254020 -        need new new prescription in 1 - 2 months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254022 -         ..
254023 -    6.  Famotidine - not listed so need new prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254025 -         ..
254026 -    7.  Calcium Carbonate - not listed so need new prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254028 -         ..
254029 -    8.  Voice continues scratchy about the same following examination                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254030 -        and recommendations by Doctor Lee during EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254031 -        190917 0730. ref SDS C0 HE9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254033 -         ..
254034 -        Voice worse past few weeks, even when concentrating on washing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254035 -        throat with carbonated beverage after each bite of food during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254036 -        meals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254038 -         ..
254039 -        Voice overall better after recent increase dilating LESV to 20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254040 -        mm has improved swallowing, compared to prior practice dilating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254041 -        to only 18 mm.  This has also improved voice function.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254043 -  ..
254044 - Asked Danise about my voice today.  She said voice seems little                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254045 - scratchy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254047 -  ..
254048 - Doctor Lee concurred voice diminished worse this morning, than it has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254049 - been in the past.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254050 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254052 -         ..
254053 -    9.  Fundoplication failing, causing continual stricture of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254054 -        requiring frequent dilation.  Doctor planned to research this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254055 -        issue during meeting on 171115 1142. ref SDS 94 XA4F  Discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254056 -        again during meeting on 180124 1130. ref SDS 97 CT56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254058 -         ..
254059 -        On 180627 1300 Doctor Patel seemed to say GI Clinic at VAMCSF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254060 -        has investigated viability of gastroscope fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254061 -        procedures.  He seemed to further advise that the clinic has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254062 -        referred patients for gastroscope full fundoplication, but not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254063 -        to repair fundoplication. ref SDS A2 JX9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254065 -         ..
254066 -        We reviewed the record in this case that Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254067 -        performed Dor fundoplication on on 091216, as shown Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254068 -        Notes received on 100928 0706. ref SDS 26 VK8F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254070 -         ..
254071 -        At tht time on 180627 1300 asked Doctor Patel to review with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254072 -        the GI team prospects to repair Dor Fundoplication in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254073 -        reduced reflux that continually causes stricture that closes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254074 -        down LESV, requiring repeated EGD dilations on close intervals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254075 -        ref SDS A2 HP4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254077 -         ..
254078 -        Discuss with Samantha Southi developing proposal for using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254079 -        gastroscope to reposition Dor fundoplication for enhanced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254080 -        reflux control.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254082 -  ..
254083 - Did not discuss today, because seem to be managing reflux well enough                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254084 - to minimize formation of stricutre, so that swallowing is not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254085 - impaired, thus avoiding vomiting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254086 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254087 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254089 -         ..
254090 -   10.  Hiatal Hernia - can this subside or otherwise improve over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254091 -        time with any action by patient, similar to ulceration of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254092 -        recovering by ending naproxen, and adding carbonated beverage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254093 -        to washout esophagus during meals?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254095 -         ..
254096 -        What drives worsening of hiatal hernia?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254098 -  ..
254099 - Doctor Lee explained this condition worsens with swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254100 - difficulty.  Since swallowing has been good the past 6 months, he may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254101 - observe improvement in the hiatal hernia during EGD examination today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254102 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254103 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254105 -         ..
254106 -   11.  Dilation 18 - 20 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254108 -  ..
254109 - Today, Doctor Lee reported dilation 15 to 19, see below. ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254110 - 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254111 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254113 -         ..
254114 -   12.  Conscious Sedation with versed - asked Doctor Lee to limit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254115 -        injection of versed to 3 mg, if feasible.  In no case do not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254116 -        exceed 5 mg, in order to avoid stroke symptoms on 160617 1637,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254117 -        ref SDS 77 5F6F, following EGD earlier that day when procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254118 -        took 30 minutes, 100% longer, and so versed was increased to 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254119 -        mg, reported on 160617 0800, ref SDS 76 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254121 -  ..
254122 - This was discussed with Doctor Lee.  He expects EGD will be completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254123 - with 2 mg versed again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254124 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254125 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254126 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254127 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254128 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254129 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254131 -  ..
254132 - OR EGD Dilation with Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254133 - EGD Dilation Procedure in OR Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254134 - 
254135 - Follow up ref SDS K2 T25I, ref SDS J7 T25I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254136 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2544 - 1346                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254501 -  ..
254502 - Vincent is nurse in the room today, and dressed in patient protection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254503 - equipment to avoid spread of coronavirus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254505 -  ..
254506 - Vincent set blood pressure cuff and EKG probes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254508 -  ..
254509 - Vincent connected sensors to monitor vitals.  He connected IV to saline                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254510 - drip, ready to apply conscious sedation drugs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254512 -  ..
254513 - EKG showed sinus.  HR bradycardia - Normal Sinus Rhythm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254515 -  ..
254516 - Mia was the technician.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254518 -  ..
254519 - Everything went smoothly in the OR today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254522 -  ..
2546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2547 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2548 - 1350 - Time Out                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
2549 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254901 - Vincent handed a small cup with lidocaine to gargle for 10 seconds.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254903 -  ..
254904 - While Doctor Lee was in the OR with Vincent and the Tech, Mia,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254905 - reviewed again objective to limit versed to 3 mg, and in no case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254906 - exceed 5 mg, in order to avoid causing a stroke, as occurred                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254907 - previously when patient received 6 mg of versed, as agreed in signing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254908 - Consent for the procedure today, per above. ref SDS H8 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254910 -  ..
254911 - After placing a bite block, Vincent covered the face with a plastic cup                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254912 - connected to oxygen.  This is a new type of equipment to reduce                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254913 - exposure to infectious virus, in this case coronavirus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254915 -  ..
254916 - Using the catheter, which Vincentise set earlier in Preparation, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254917 - above, ref SDS J5 JA4N, Vincent applied Fentanyl, then Benadryl and finally                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254918 - versed for conscious sedation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254920 -  ..
254921 - The team then did the EDG/dilation procedure with Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254923 -  ..
254924 - Gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254925 - Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254926 - Start Time........... 1403                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254927 - Procedure Stop....... 1424                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254929 -  ..
254930 - Time for procedure...... 21 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254931 -                          --                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254932 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254933 -     This is about twice as long as prior 65 procedures.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254934 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254935 -     Procedure today took longer, because the doctor had 3 observers,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254936 -     so there was time for questions and explanations.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254938 -  ..
254939 - Nursing Procedural Sedation & Analgesia Flow Sheet Record - Page 1 of 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254940 - Versed total................   2 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254941 - Fentanyl total.............. 200 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254942 - Benadryl....................  50 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254943 - Lidocaine...................   4 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254944 - IV Fluids normal saline.....     ML  no report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254945 - Triamcinalone...............  20 mg injected 2 shallow mucosal tears                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254946 - Saline...................... 200 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254948 -  ..
254949 - During procedure while asleep...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254951 -  ..
254952 - Blood pressure 156/94 to 129/85  Heart Rate 70 - 42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254953 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254954 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254956 -  ..
254957 - Nurses note unreadable.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254959 -  ..
254960 - EKG shows patient in sinus...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254961 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254962 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254963 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254964 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254966 -  ..
254967 - LESV Contact 0 MM Dilation 18 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254968 - Meeting Doctor Lee EGD Dilation 18 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254969 - Ulceration Resolved Meeting Doctor Lee EGD Dilation 18 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254970 - 
254971 - Follow up ref SDS K2 5H5J, ref SDS J7 5H5J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254972 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254973 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254975 -  ..
2550 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2551 - 1530                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2552 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255201 - Woke in recovery see Nursing Post-procedure care record.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
255202 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255203 - Gracie assisted.  Other nurses came by to say hello.  Frank commented:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255204 - "He never gets older."                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255206 -  ..
255207 - IV removed and dressed at 1147                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
255209 -  ..
255210 - Took photographs of Nurses notes showing who did the work, vitals,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
255211 - time of procedure and medications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
255213 -  ..
255214 - Blood pressure 110/70 to 165/95  Heart Rate 50 - 60                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255215 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255216 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
255217 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255218 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255219 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255220 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255222 -  ..
2553 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2554 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2555 - 1553                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2556 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255601 - Doctor Lee arrived.  The doctor said he ordered new prescriptions for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255602 - Famitodine and Pantoprazole, discussed earlier today, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255603 - ref SDS 0 GY6K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
255605 -  ..
255606 - Doctor Lee indicated that achalasia worsened this past cycle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255608 -  ..
255609 - LESV contracted to 15 mm from 18 mm dilated during the last procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255610 - 4 months ago on 240507 0930. ref SDS K2 KH6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
255612 -  ..
255613 - This was notably worse condition compared to prior 6 years, dilating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255614 - LESV to 20 mm, but continued better than severe weekly contractions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255615 - during 160816 - 170905, shown in case study below. ref SDS K2 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
255617 -  ..
255618 - The doctor further advised there was no evidence found of ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255619 - on LESV, which was a concern after resuming use of Naproxen to manage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255620 - pain and inflammation during hiking.  Naproxen has since been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255621 - stopped, as it may have contributed to colitis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255623 -  ..
255624 - Doctor Lee explained dilating the balloon from 15 mm to 19 mm.  At that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255625 - point, the baloon caused a slight tear in tissue.  He therefore did                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255626 - not dilate to 20 mm, as has been done for 5 years, beginning on 181002                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255627 - 0800. ref SDS A7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
255629 -  ..
255630 - There was slight bleeding from small break in LESV tissue.  He wants                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255631 - to continue Mylanta to be last medication taken before sleeping, so it                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255632 - will coat the tear area and treat it to heal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255634 -  ..
255635 - Versed was limited today, to only 2 ml, as discussed during the "Time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255636 - Out" meeting before the procedure, per above. ref SDS 0 639M and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255637 - ref SDS 0 KL7O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
255639 -  ..
255640 - The doctor indicated current medication and eating regimen, per above,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255641 - ref SDS 0 FV8H, should continue to maintain recovery from prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255642 - achalasia difficulties, i.e., work today demonstrated strong response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255643 - to treatment recovering from achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255645 -  ..
255646 - Triamcinalone was injected to help heal the tear and maintain LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
255647 - dilation.  Not clear the amount.  Does seem to be listed on under                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
255648 - drugs administered, per above. ref SDS I3 CR4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255650 -  ..
255651 - Apparently no biopsies were taken during this procedure today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
255653 -  ..
255654 - Doctor Lee seemed to indicate he resolved bloating issue that has been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255655 - continuous the past several months, and discussed last week with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255656 - Doctor Pelligrini on 240905.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
255657 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255658 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255659 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255660 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255661 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255662 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2557 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 K2 XM3J, ref SDS J7 XM3J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260406 - Today, was EGD #68                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260408 -  ..
260409 -                                                                  Bena                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260410 -                                                         Versed/  dryl                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260411 -                    ** MEDICATIONS LESV DILATE  Triamcin Midaz   Diphenhy  Fenta  Lido                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260412 -        Months          PPI FMTDN   from -  to    olone  olam    dramine    nyl   caine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260413 -      Interval  Date     mg   mg     mm     mm      mg     mg      mg       mg     mL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260414 -          4     240910   40  160     15     19....100.0.....2......50......200.....04.... ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260415 -          4     240507   40  160     15     18....100.0.....2......50......150.....04.... ref SDS K2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260416 -          4     240116   40  160     18     19....100.0.....3......50......200.....04.... ref SDS J7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260417 -          6     230908   40  160     18     18....100.0.....3......50......200.....04.... ref SDS J5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260418 -          6     230303   40  160     19     20....100.0.....3......50......150.....04.... ref SDS I9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260419 -          6     220805   40  160     19     20....100.0.....3......50......150.....04.... ref SDS I3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260420 -          5     220204   40  160     18     20....100.0.....3......50......200.....04.... ref SDS H8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260421 -          6     210905   40  160     18     20......0.0.....3......50......150.....04.... ref SDS G8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260422 -          4     210305   40  160     19     20......0.0.....3......50......150.....04.... ref SDS G6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260423 -          2     201106   40  160     20     20......0.0.....3......50......150.....04.... ref SDS F9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260424 -          2     200908   40  160     19     20......0.0.....2......50......100.....10.... ref SDS F2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260425 -          2     200707   40  160     19     20......0.0.....2......50......100.....10.... ref SDS E6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260426 -          2.5   200529   40  160     19     20......0.0.....2......50......100.....10.... ref SDS D4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260427 -          2     200310   40  160     19     20......0.0.....3......50......150.....10.... ref SDS C8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260428 -          2     200110   40  160     19     20......0.0.....3......50......150.....10.... ref SDS C6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260429 -          2     191112   40  160     19     20......0.0.....3......50......150.....10.... ref SDS C1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260430 -          1     190917   40  160     19     20......0.0.....3......50......150.....10.... ref SDS C0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260431 -          1     190813   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260432 -          1     190709   40  160     20     20......0.0.....3......50......150.....10.... ref SDS B8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260433 -          1     190618   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260434 -          1     190521   40  160     18     20......0.0.....3......50......200.....10.... ref SDS B6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260435 -          1     190416   40  160     18     20....100.0.....3......50......200.....10.... ref SDS B5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260436 -          1     190319   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260437 -          1     190215   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260438 -          1     190118   40  160     18     20......0.0.....3......50......150.....10.... ref SDS B0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260439 -          1     181218   40  160     18     20......0.0.....4......50......150.....10.... ref SDS B0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260440 -          1     181127   40  160     18     20......0.0.....3......25......250.....10.... ref SDS A9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260441 -          1     181030   40  160     18     20......0.0.....3......25......250.....10.... ref SDS A8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260442 -          1     181002   40  160     18     20......0.0.....3......25......250.....10.... ref SDS A7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260443 -          1     180904   40  160     16.5   19......0.0.....3......25......250.....10.... ref SDS A5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260444 -          1     180814   40  160     16     19......0.0.....3......25......250.....10.... ref SDS A4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260445 -          0.5   180713   40  160     16.5   18......0.0.....3......25......250.....10.... ref SDS A3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260446 -          2.5   180627   40  160     12     16.5....0.0.....3......25......250.....10.... ref SDS A1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260447 -          2     180417   40  160     16.5   19......1.0.....3......25......250.....10.... ref SDS 99 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260448 -          1.50  180227   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS 98 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260449 -          1.25  180109   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS 96 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260450 -          1     171128   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS 95 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260451 -          2     171031   40  160     15.5   18......1.0.....4......25......250.....10.... ref SDS 93 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260452 -          1.53  170905   80   80     15     18......1.0.....3......25......250.....10.... ref SDS 92 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260453 -          1.53  170516   80   80     16.5   19......1.0.....5......25......250.....10.... ref SDS 91 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260454 -          1.53  170404   80   80     16.5   18......1.5.....5......25......200.....10.... ref SDS 90 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260455 -          1.53  170221   80   80     15     18......2.0.....5......25......200......5.... ref SDS 89 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260456 -          0.80  170106   80   80     16.5   18......2.0.....5......25......200......5.... ref SDS 88 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260457 -          0.23  161213   80   80     15     18......3.0.....5......25......200......5.... ref SDS 87 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260458 -          0.20  161206   80   80     11     16.5....1.0.....5......25......200......5.... ref SDS 86 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260459 -          0.27  161130   80   80     11     15......0.0.....5......25......200......5.... ref SDS 84 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260460 -          0.23  161122   80   80      6     12......0.0.....5......25......200......5.... ref SDS 82 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260461 -          1.40  161115   42   80     10     10......0.0.....5......25......200......5.... ref SDS 81 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260462 -          0.83  161004   26   80     11     15......5.0.....5......25......200......5.... ref SDS 80 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260463 -     *1   0.80  160909   80    0     10     15......5.0.....5......25......200......5.... ref SDS 79 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260464 -          2     160816   11   40      9.5   10......5.0.....4......50......150......5.... ref SDS 78 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260465 -          3     160617   10   40      9.5   15......5.0.....6......50......250......5.... ref SDS 76 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260466 -     *2   3     160315   15   40      9.5   15......3.0.....5......25......250......5.... ref SDS 75 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260467 -          8     151204   32   20     10     15......5.0.....5......25......200......5.... ref SDS 72 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260468 -     *3   6     150421   41          16.5   18......3.0.....4......50......250......5.... ref SDS 62 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260469 -          6     141107   37          15     18......4.0.....5......50......150......5.... ref SDS 59 E54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260470 -          6     140509   24          16.5   18..............5......50......200......5.... ref SDS 53 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260471 -     *4   7     131115   24          16.5   18......2.0.....4......50......200......5.... ref SDS 47 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260472 -          3     130416   38          18     18......2.0.....5......50......250......5.... ref SDS 46 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260473 -          4     130110   39          15     18......3.0.....4......50......100......5.... ref SDS 45 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260474 -     *5   6     120925   38          15     18......4.0.....5......50......200......5.... ref SDS 44 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260475 -     *6   4     120322   27          16.5   18..............4......50......150......5.... ref SDS 42 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260476 -     *7   3     111115   76          16.5   18..............4......50......200......5.... ref SDS 39 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260477 -          4     110819   80          15     16.5....2.5.....5......50......200......5.... ref SDS 38 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260478 -          2     110429   80          13     16.5....3.5.....5..............200......5.... ref SDS 35 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260479 -          2     110218   80          11     14......2.0.....4......50......150......5.... ref SDS 34 SS5R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260480 -          4     101210   40          11     14......................................5.... ref SDS 30 BF6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260481 -          6     100827    4          11     15..............5......50......250......5.... ref SDS 25 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260482 -          3     100305    0          11     15..............5......50......250......5.... ref SDS 24 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260483 -          -     091216               Heller Myotomy Fundoplication................. ref SDS 22 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260484 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260486 -         ..
260487 -     ** Dates are from case study on exercise, diet, vitals and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260488 -        medication, shown on 160101, ref SDS 74 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260489 -        previously on 140101. ref SDS 50 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260490 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260491 -     *1 On 160911 paused Pantoprazole to reduce dehydration through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260492 -        frequent urination until after Half Dome, and resumed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260493 -        160920.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260494 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260495 -     *2 On 151210 begin Omeprazole 20 mg every other day. ref SDS 50 E64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260496 -        Resumed Omeprazole 20 mg on 160323. ref SDS 74 RSXR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260498 -         ..
260499 -        On 150924 hospitalized hematoma debridement; begin Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260500 -        20 mg per day. ref SDS 50 JT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260502 -     *3 On 150920 about 5 attacks convulsions, nausea not taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260503 -        Omeprazole - took 40 mg. ref SDS 50 656M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260505 -     *4 On 131115 Doctor Lee prescribed Omeprazole 40 mg 1 month then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260506 -        20 mg for next 5 months. ref SDS 47 ZY5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260508 -         ..
260509 -     *5 On 130106, 4 days before EGD on 130110, reduced Omeprazole to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260510 -        20 mg per day, shown in case study on 120101 0900, ref SDS 41                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260511 -        AD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260512 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260513 -     *6 On 120907 Doctor Egan research found Omeprazole increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260514 -        blood pressure, sensed possible correlation patient sudden                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260515 -        rise in blood pressure, recommended reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260516 -        to 20 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260517 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260518 -     *7 On 11115 Doctor Lee prescribed continue PPI 80 mg; on 111201,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260519 -        patient reduced dose to 20 mg on record of rising blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260520 -        pressure despite increased hiking; research indicated PPI may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260521 -        elevate blood pressure, see case study 101010 0744, ref SDS 27 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260525 -  ..
260526 - Conscious Sedation Reduced Dose Applied for 17 Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260527 - 
260528 - Follow up ref SDS K2 714N, ref SDS J7 714N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260529 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260530 - Nursing Procedural Sedation & Analgesia Flow Sheet Record Page 1 shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260531 - versed 2 ML, even though the procedure took 32 minutes, ref SDS K2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260532 - UT4N, Limiting versed to 2 mg, aligned with discussion prior to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260533 - starting the procedure, per above, ref SDS K2 KL7O,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260535 -  ..
260536 - No post procedure side effects as occurred previously on 161213 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260537 - ref SDS 87 R74J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260539 -  ..
260540 - Seem sleepy though even hours after the procedure using 2 ml versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260541 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260546 -  ..
260547 - Ulceration on Esophagus Above LESV Significantly Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260548 - 
260549 - Follow up ref SDS K2 RZ3G, ref SDS J7 RZ3G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260550 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260551 - Doctor Lee reported this morning that EGD procedure found that both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260552 - ulcerations on the side of esophagus above LESV continue to be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260553 - completely resolved, reported following EGD on 190917 0730.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260554 - ref SDS C0 RZ3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260556 -  ..
260557 - The doctor said the small ulceration found during procedure 16 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260558 - ago, continues completely resolved today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260560 -  ..
260561 - Triamcinalone was injected to aid healing of the small tear during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260562 - dilation, and to maintain dilation opening diameter - see case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260563 - above. ref SDS K2 YR4H  Not sure of the amount.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260565 -  ..
260566 - Doctor Lee did not have time to present pictures showing improved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260567 - condition with reduced ulceration of LESV, following EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260568 - procedure today, per above. ref SDS K2 OM7J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260570 -  ..
260571 - Doctor Lee explained plans to further research continuing pentoprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260572 - everyday before dinner for next 4 months, and to prescribe a new PPI                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260573 - that does not raise blood pressure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260574 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260575 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260576 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260577 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260579 -  ..
260580 - Discharge Instructions and Schedule Next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260581 - Schedule Next Procedure and Post Procedure Review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260582 - 
260583 - Follow up ref SDS K2 XF6X, ref SDS J7 XF6X.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260584 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260585 - Doctor Lee feels results today, show achalasia has further degraded                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260586 - LESV.  He scheduled next procedure in 2 months, actually before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260587 - Thanksgiving on 2401128.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260589 -  ..
260590 - He said to call the front desk in a few days to schedule an overbook                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260591 - for next EGC before Thanksgiving.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260592 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260593 -            [On 240918 0900 call from Chari at VAMC Sacramento;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260594 -            scheduled next EGD on 241126 1300. ref SDS L1 E84I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260595 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260597 -  ..
2606 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2608 - 1615                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2609 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260901 - Discharge Instructions...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260902 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260903 -         Dilation.... 15..... 19                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260905 -          ..
260906 -         Repeat EGD in 2 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260908 -          ..
260909 -         Continue carbonated softdrinks to clear the throat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260911 -          ..
260912 -         Things to remember after receiving sedation?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260913 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260914 -            1.  Do not drive a car.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260915 -            2.  Do not drnk alcohol                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260916 -            3.  Do not operate heavy machinery or power tools                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260917 -            4.  Do not sign legal or financial documents                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260918 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260920 -  ..
260921 - On way out of clinic, forgot to order from ROI progress notes for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260922 - meeting today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260924 -  ..
260925 - May be able to get them from VA online services.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260926 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260927 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260928 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260929 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260930 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260931 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260932 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2610 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 K2 Q05K, ref SDS J7 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 - Request is for information to be delivered to the individual...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270421 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270422 -        x  CD-ROM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270424 -  ..
270425 - Stored Progess Notes for procedure on 240910 at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270426 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270427 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270428 -              F:\05\00003\SM\CC\AGMJ\20240910-130000\mhv_WELCH_20240915_1339.txt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270430 -  ..
270431 - File may require password... 03011945 (birthday)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270432 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270434 -  ..
270435 - This file includes photographs taken during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270436 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270437 -        Sacramento VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270438 -        10535 Hospital Way Mather CA, 95655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270439 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270440 -        Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270442 -         ..
270443 -        Date/Time:               10 Sep 2024 @ 1753                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270444 -        Note Title:              EGD Procedure Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270445 -        Location:                No CA Healthcare Sys-Martinez                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270446 -        Signed By:               CLINICAL,DEVICE PROXY SERVICE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270447 -        Date/Time Signed:        10 Sep 2024 @ 1753                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270448 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270450 -         ..
270451 -        LOCAL TITLE: EGD Procedure Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270452 -        STANDARD TITLE: GASTROENTEROLOGY DIAGNOSTIC STUDY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270453 -        DATE OF NOTE: SEP 10, 2024@17:53:15  ENTRY DATE: SEP 10, 2024@17:53:15                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270454 -        AUTHOR: CLINICAL,DEVICE PRO  EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270455 -        URGENCY:            STATUS:  COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270456 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270457 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270458 -        ** DOCUMENT IN VISTA IMAGING **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270459 -        SEE FULL REPORT IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270461 -         ..
270462 -        SIGNATURE NOT REQUIRED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270463 -        SEE SIGNATURE IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270464 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270465 -        ** (PENTAX EGD)  AUTO-INSTRUMENT DIAGNOSIS **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270467 -         ..
270468 -        Procedure: EGD  UPPER ENDOSCOPY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270470 -         ..
270471 -        PENTAX INSTRUMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270472 -        10535 Hospital Way Mather CA, 95655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270473 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270475 -         ..
270476 -        EGD PROCEDURE REPORT     EXAM DATE: 09/10/2024                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270477 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270478 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270486 -         ..
270487 -        INDICATIONS:  The patient is a 79 yr old male here for an EGD due to recurrent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270488 -        GERD stricture post 2009 achalasia myotomy..                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270489 -        PROCEDURE PERFORMED:  EGD, diagnostic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270490 -        EGD w/ balloon dilation of esophagus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270491 -        EGD w/ directed submucosal injection(s), any substance                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270492 -        MEDICATIONS:     Midazolam (Versed) 2 mg IV, Fentanyl 150 mcg IV, and Benadryl                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270493 -        50 mg IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270494 -        TOPICAL ANESTHETIC:     Lidocaine Gargle                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270496 -         ..
270497 -        CONSENT:  The risks, benefits, and alternatives to this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270498 -        procedure including but not limited to the risks of bleeding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270499 -        and bowel perforation were explained to the patient.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270500 -        patient understood and provided written informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270502 -  ..
270503 - See understandings signing consent during meeting with the doctor, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270504 - above. ref SDS 0 KT9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270506 -  ..
270507 - EGD PROCEDURE REPORT continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270508 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270509 -        DESCRIPTION OF PROCEDURE:  In the Sacramento VA GI Endoscopy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270510 -        Unit,  Informed consent was verified, confirmed and timeout was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270511 -        performed.  The patient was placed in left lateral decubitus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270512 -        position.  Oxygen was administered.  Continuous oximetric and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270513 -        hemodynamic monitoring was initiated.  Intravenous sedation was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270514 -        administered in divided doses.  After a bite block was placed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270515 -        in the patient's mouth,  the Colonoscopes, GIF - H190, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270516 -        GIF-H190-2164934 videoscope was introduced under direct vision                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270517 -        through the mouth and advanced to the third portion of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270518 -        duodenum.  Retroflexion was performed in the stomach and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270519 -        revealed a hiatal hernia.  The stomach and esophagus were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270520 -        decompressed, and the gastroscope removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270521 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270523 -         ..
270524 -        ADVERSE EVENTS:     There were no complications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270526 -         ..
270527 -        IMPRESSIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270529 -         ..
270530 -        RECOMMENDATIONS:     EGD + TTS balloon dilation + triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270531 -        injection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270533 -         ..
270534 -        79 yo man with achalasia and post-myotomy recurrent GERD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270535 -        stricture since 2010.  Last dilation 2024 May to 18mm.  Has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270536 -        noted increased saliva build up over the past 4 weeks, as well                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270537 -        as dysphagia to a large OTC magnesium supplement tablet.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270538 -        notes some increased abdominal bloating for which he reduced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270539 -        his usual vigorous activity due to concern it might be a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270540 -        recurrence of ischemic colitis. 6/2024 had cardiac ablation at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270541 -        SFVA for recurrent atrial flutter.  No symptomatic recurrences                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270542 -        since.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270544 -  ..
270545 - Report of bloating aligns with meeting reported above. ref SDS 0 RK4I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270547 -         ..
270548 -        Versed 2mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270549 -        fentanyl 200mcg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270550 -        Benadryl 50mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270552 -         ..
270553 -        TOPICAL ANESTHETIC:  Lidocaine Gargle                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270554 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270555 -        start 1403                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270556 -        end 1424     = 21 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270557 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270558 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270559 -        1.  Proximal and mid esophageal body dilated and aperistaltic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270561 -             ..
270562 -        2.  Tattoo site in the esophageal body at about 31 cm again                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270563 -            noted without evidence of mass effect or ulceration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270565 -             ..
270566 -        3.  Esophageal stricture located at the GE junction at 38 cm,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270567 -            estimated diameter of 16.5mm measured by TTS balloon.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270568 -            Small mucosal tears noted with balloon dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270569 -            16.5-18-19mm until pressure stabilization over 10 minutes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270570 -            Triamcinolone acetate 20mg/ml 0.25ml x4 injected into edges                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270571 -            of mucosal tears.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270573 -             ..
270574 -        4.  Diaphragm located at 40cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270576 -             ..
270577 -        5.  Normal-appearing gastric mucosa in the fundus and body.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270578 -            Gastric fundus appearance consistent with known history of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270579 -            fundoplication with relaxation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270581 -             ..
270582 -        6.  Gastric mucosa in the antrum with patchy erythema but no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270583 -            ulceration, erosion, or mass effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270585 -             ..
270586 -        7.  Normal pylorus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270588 -             ..
270589 -        8.  Normal duodenum to D3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270590 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270592 -         ..
270593 -        Impression:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270594 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270595 -        1.  Distal esophageal stricture due to GERD with mild reduction                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270596 -            in GE junction lumen diameter since last dilation of May                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270597 -            2024, suggesting continued indication for proton-pump                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270598 -            inhibitor therapy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270600 -             ..
270601 -        2.  Dilated aperistaltic esophageal body consistent with known                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270602 -            diagnosis of achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270604 -             ..
270605 -        3.  Probable increased sensitivity to dysphagia with any small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270606 -            reduction in lumenal diameter due to aperistalsis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270607 -            esophageal body.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270609 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270611 -         ..
270612 -        Recommend:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270613 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270614 -        1.  Continue flushing of esophagus with liquid after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270615 -            medications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270616 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270617 -        2.  Repeat EGD & dilation in about 2 months; attempt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270618 -            dilation to goal of 20mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270620 -             ..
270621 -        3.  Continue avoidance of oral NSAIDs.  Patient will try                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270622 -            acetaminophen, starting at 1000mg / day up to a maximum of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270623 -            3000mg / day for effectiveness on pain relief.  HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270624 -            baseline levels drawn today.  If effective pain relief dose                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270625 -            achieved then recheck HDL levels after 1 month to determine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270626 -            effect on HDL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270628 -             ..
270629 -        4.  Continue current anti reflux and acid suppression /                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270630 -            neutralization regimen: famotidine 80mg twice daily +                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270631 -            pantoprazole 40mg daily, 30 minutes before a meal + liquid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270632 -            antacid + oral calcium carbonate tablets.  Would not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270633 -            recommend full cessation of proton pump inhibitor due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270634 -            continued slow closure of esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270636 -             ..
270637 -        5.  Build up of saliva in esophagus may be flushed with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270638 -            carbonated beverages.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270639 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270641 -         ..
270642 -        REPEAT EXAM:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270643 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270645 -         ..
270646 -        Randall Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270647 -        eSigned:  Randall Lee, MD 9/10/2024 5:52:59 PM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270648 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270649 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270650 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270651 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270652 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270653 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270654 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270655 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270656 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270657 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270658 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270659 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270660 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270661 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270662 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270663 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270664 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270665 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270666 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270667 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270668 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270669 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270670 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270671 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270672 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2707 -