CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2503 -    ..
2504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
2505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250501 - Follow up ref SDS L7 0000. ref SDS L2 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 L7 E84I, ref SDS L2 E84I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251805 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251806 - EGD treatment with Doctor Lee today, was scheduled for 2 months by the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251807 - doctor after the EGD on 240910 1300. ref SDS K7 XF6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251808 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251809 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251810 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251811 -              https://www.myhealth.va.gov/mhv-portal-web/home                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251813 -  ..
251814 - Customer....                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251818 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251820 -  ..
251821 - Doctor Lee was doing EGD procedures every 6 months, Schedule was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251822 - updated by Jessica extending procedures to Jan of 2022, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251823 - 201106 0930, ref SDS F9 D45N  After procedure on 210305, the doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251824 - said patient is doing so well that next procedure would be in 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251825 - on 210905, reported on 210305 0930. ref SDS G6 PJ5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251827 -  ..
251828 - However, after the last EGD, Doctor Lee changed the duration to 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251829 - months, reported on 240910 1300. ref SDS K7 XF6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251830 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251832 -  ..
251833 - Applied EGD pre-proc requirements for NPO after midnight, from letter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251834 - on 101015 1547. ref SDS 28 4J9L  Last food was at......                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251835 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251836 -                         241125 1830                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251838 -  ..
251839 - This morning, drove to Sacramento from Concord, and stayed at Amy's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251840 - house in Elk Grove about 20 miles from VAMC Sacramento.  Kathy died on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251841 - 230716 0741. ref SDS J2 GF7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251843 -  ..
251844 - This morning, Amy drove us to the hospital.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251845 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251846 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251848 -  ..
2519 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2521 - 0810                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252201 - Arrived at VAMC Sacramento.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252203 -  ..
252204 - _____ new attendant did check-in to GI Department at the customer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252205 - counter.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252207 -  ..
252208 - Amy's cell phone for designated driver...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252212 -  ..
252213 - Amy signed the discharge form affirming she will be designated driver,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252214 - and responsible to facilitate no driving for 24 hours, and following                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252215 - up Kathy passing away on 230716 0741. ref SDS J2 0T5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252216 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252217 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252218 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252220 -  ..
2523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2524 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2525 - 0820                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252601 - Connie and Gracie did vitals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252603 -  ..
252604 - Vitals were taken and found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252606 -            Weight.................. 173                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252607 -            BP...................... 135 61                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252608 -            HR (pulse).............. 70                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252609 -            Oxygen..................                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252610 -            Temp....................                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252611 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252612 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252613 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252614 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252616 -  ..
2527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2529 - 0830                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253001 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253002 - 
253003 - Follow up ref SDS L7 Y68O, ref SDS L2 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 - In the GI Clinic, Gracie helped with patient gown and setup on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253010 - gurney.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253012 -  ..
253013 - Nursing staff - everyone said hello...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253014 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253015 -           Danise............. now working part time only on Tuesdays - said hello and got a hug                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253016 -           Connie............. check-in, vitals and document setup                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253017 -           Shawna............. She set IV today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253018 -           Gracie............. She entered patient histry and set IV for versed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253019 -           Grace.............. said hello                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253020 -           Mimi............... said hello                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253021 -           Rodalie............ She is charge of the nurse team now                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253022 -           Hazel.............. Said was nurse in OR today, did time out and administered versed conscious sedation drug                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253023 -           Rachel............. She has not done Whitney recently, looking forward to hiking Half Dome but nothing scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253024 -           Lara............... not at work today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253025 -           Frank.............. Frank helped in recovery today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253026 -           Tanya.............. did not see her                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253027 -           Vince.............. Did computer input today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253028 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253030 -  ..
253031 - Rachel came over and visited for few minutes.  Showed pictures of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253032 - recent hike in Auburn.  She is planning trip to Yosemite this summer.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253034 -  ..
253035 - Vince entered patient history in the computer.  Most information                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253036 - entered today, for patient identification and medical history is the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253037 - same and therefore is copied from the prior record on 241126 1300.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253038 - ref SDS L2 1X6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253040 -  ..
253041 - Advised new symptoms of dysfunctional autonomic nervous system,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253042 - reported to Doctor Pellegrini on 250114 1202. ref SDS L3 NA4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253043 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253044 -            varying heart rate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253045 -            fatigue                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253046 -            bloating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253047 -            chest pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253048 -            blood pressure elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253049 -            heart rate elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253050 -            fainting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253051 -            hallucinations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253052 -            seizures - loss motor control while hiking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253053 -            fell  during hike on 240924, see case study... 240101 0712, ref SDS J7 PYSX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253054 -            cardiac colitis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253055 -            Hiking declined 90%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253056 -            voice disrutption (could HRV/ANS be disrupting larynx?)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253058 -               ..
253059 -              On 250211 0830 may need addendum to Comorbidities section                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253060 -              adding the above symptoms. at ref SDS L7 HY9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253062 -  ..
253063 - Vince is not familiar with dysfunctional ANS.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253065 -  ..
253066 - This was later discussed with Doctor Lee when he obtained consent for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253067 - the procedure, see below. ref SDS 0 6H8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253068 - the procedure, see below. ref SDS L7 6H8N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253069 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253071 -  ..
253072 - Shawna set catheter IV for sedation.  He asked for best location to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253073 - get a good vein.  Explained inner right elbow right side vein has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253074 - worked well for recent blood draws and IV.  Did not do 10 pushups with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253075 - feet on chair to improve blood flow about an hour before arriving at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253076 - hospital.  Veins develop adhesions (scar tissue) that take time to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253077 - heal, and prevent blood flow into the IV needle.  This morning ran hot                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253078 - water on right forearm in the shower to dilate veins, which helped to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253079 - get blood flow on 1st stick today.  Gracie used this location at inner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253080 - right side and below elbow - pain level 4, but only momentary.  It was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253081 - successful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253083 -  ..
253084 - Case study on sticks required to set catheter is reported on 110429                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253085 - 1230. ref SDS 36 UO3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253086 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253087 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253088 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253089 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253091 -  ..
2531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2533 - 1121                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253401 - Meeting Doctor Lee and Consent for Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253402 - 
253403 - Follow up ref SDS L7 GG6G, ref SDS L2 GG6G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253404 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253405 - Doctor Lee asked questions on patient history to verify ready for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253406 - procedure, e.g., no allergies, and NPO after midnight to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253407 - conflicts with anesthesia; no health problems, e.g., no diabetes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253408 - alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253410 -  ..
253411 - Doctor Lee asked about medication protocol?  Reported protocol he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253412 - prescribed after EGD on 190416 1000. ref SDS B5 JK6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253414 -  ..
253415 - This morning he confirmed the following prescription...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253416 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253417 -    **  Famotidine................0700.... 2 40mg pills in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253418 -        Lisinopril ...............0700.... 1 10mg pill in morning - started 250406                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
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 - Previously, Doctor Lee recommended taking Mylanta last at night to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253445 - coat throat and LEAV, protecting against achalasia, reported on 240507                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253446 - 0930. ref SDS K3 K54L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253448 -  ..
253449 - Continued doing this during current cycle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253450 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253451 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253453 -  ..
253454 - Nutrition taken during hikes every 5 - 10 miles...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253455 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253456 -        softdrink carbonated.............. hydration and swallowing meds and nutrition                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253457 -        magnesium......................... for energy and resolve inflammation caused by injuries, e.g., feet and knees                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253458 -        peanut butter..................... for protein and magnesium - energy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253459 -        avocado........................... for HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253460 -        margarine......................... help swallow peanut butter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253461 -        Chia seeds........................ for electrolytes and energy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253462 -        CoQ10............................. aids heart and liver - big energy boost for hills and HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253463 -        electrolytes...................... replace from sweating while hiking in elevated temperatures                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253465 -  ..
253466 - Hiking has significantly declined, shown in report to Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253467 - Pellegrini in the letter on 250114 1202, ref SDS L3 9T85, and entered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253468 - below. ref SDS L7 1X6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253470 -  ..
253471 - Need new prescriptions for...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253472 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253473 -        Calcium Carbonate.............. - 0 refills - not listed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253474 -        Pantoprazole.. new prescription - 1 refills scheduled to be filled on 250227, then 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253475 -        Famotidine.... new prescription - 0 refill - not listed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253476 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253477 -            [...below on 250211 0830 at 1150 after the procedure Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253478 -            Lee said he ordered new prescriptions. ref SDS L7 KH6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253479 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253480 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253481 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253482 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253483 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253484 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253486 -  ..
253487 - Lab Test HDL Treating Atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253488 - 
253489 - Follow up ref SDS L7 IF8I, ref SDS L2 IF8I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253490 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253491 - Doctor Lee ordered lab to test lipids - HDL in accordance with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253492 - recommendations to test Acetaminophen pain medication, reported in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253493 - progress notes on 240507 0930. ref SDS K3 F76G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253495 -  ..
253496 - Evaluate frequent urination - a1c lab for diabetes was negative on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253497 - 240212 0937. ref SDS J9 2P6O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253499 -  ..
253500 - Frequent urination seems increased lately, see study. ref SDS C2 F29N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253504 -  ..
253505 - Paroxysmal Atrial Fibrillation Treated Ablation Pulmonary Vein Isolation on 200430                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253506 - Right Atrial Flutter Treated Ablation on 200511                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253507 - Vision Diminished Fatigue Sleepy Taking Metoprolol Treatment PAF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253508 - 
253509 - Follow up ref SDS L7 XN5F, ref SDS L2 XN5F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253510 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253511 - On 200430 0700 left atrial ablation performed by Doctor Pellegrini.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253512 - ref SDS C9 9C9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253514 -  ..
253515 - On 200511 0546 at 1342 went to ASU for preparation to do ablation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253516 - ref SDS D2 244I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253518 -  ..
253519 - On 200527 0930 telecon meeting with Doctor Pellegrini advised ablation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253520 - procedures successfully treated atrial fibrillation and atrial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253521 - flutter. ref SDS D3 JJ6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253523 -  ..
253524 - On 201210 0700 3rd cardiac ablation and 2nd for right atrial to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253525 - resolve recurrent atrial flutter. ref SDS G3 4H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253527 -  ..
253528 - On 211115 0900 4th cardiac ablation and 2nd for left and right atrials                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253529 - to resolve recurrent atrial fibrillation. ref SDS H3 XV7S                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253531 -  ..
253532 - On 231214 0630 5th cardiac ablation for AFL atypical in left atrial.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253533 - ref SDS J6 VZ5L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253535 -  ..
253536 - On 240611 0930 6th cardiac ablation for AFL atypical in left atrial,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253537 - making corrections to 5th ablation. ref SDS K5 P85O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253539 -  ..
253540 - Had 26 AFL episodes last year, listed on 200101 0701. ref SDS C2 H54I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253541 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253542 -        Digestive problems:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253544 -        "...patients have trouble moving food through their GI tract                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253545 -        after ablation.  Symptoms include reflux, feeling bloated, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253546 -        intolerance of big meals, while signs may include distention of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253547 -        the abdomen.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253549 -  ..
253550 - See research on 200508 0916. ref SDS D1 OS49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253552 -  ..
253553 - Past few months, seems like stomach pressure/bloating is occurring                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253554 - more often during hikes, so taking more Simethicone.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253556 -  ..
253557 - Research found Pantoprazole can cause bloating and stomach pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253558 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253559 -        See Side Effects (Incidence not known)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253560 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253561 -              https://www.mayoclinic.org/drugs-supplements/pantoprazole-oral-route/side-effects/drg-20071434?p=1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253562 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253563 -            On 220811 0728 letter to Gracie for Doctor Lee to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253564 -            investigate ischemic colitis causing bloating. ref SDS I4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253565 -            KR86                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253566 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253568 -  ..
253569 - Pantoprazole can cause blurred vision.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253571 -  ..
253572 - Actually, looks like Famotidine also causes bloating.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253573 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253574 -              https://www.netdoctor.co.uk/medicines/digestion/a7327/famotidine/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253575 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253576 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253577 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253578 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253580 -  ..
253581 - Recovery from Achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253582 - Swallowing Has Been Effective Past 4 Months Until 1 Month Ago                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253583 - 
253584 - Follow up ref SDS L7 VV6N, ref SDS L2 VV6N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253586 -  ..
253587 - Eating regimen including carbonated drinks with meals to clear                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253588 - esophagus is shown in case study of daily diet, medication, exercise                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253589 - and vitals, reported on 220101 0635. ref SDS H4 PUSQ                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253591 -  ..
253592 - Reviewed eating practice - seem to have recovered from former                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253593 - difficulties swallowing due to achalasia.  Esophagus has regained lost                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253594 - strength; now able to push food through Lower esophagual sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253595 - valve (LESV).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253597 -  ..
253598 - Vomiting the past cycle... 240101 0712, ref SDS J7 U73I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253599 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253600 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253602 -  ..
253603 - Drinking carbonated (Coca Cola mixed with lemon and orange juice)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253604 - cleared throat.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253606 -  ..
253607 - Bubbles clogging LESV seems increased past 3 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253609 -  ..
253610 - Voice fades significantly at times, likely related to buildup of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253611 - saliva in esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253613 -  ..
253614 - Doctor Lee noted voice this morning is weaker than normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253616 -  ..
253617 - Burping stable and increased compared to last cycle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253619 -  ..
253620 - Doctor Lee noted a burp while we talked and asked if this occurs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253621 - routinely?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253623 -  ..
253624 - Barium swallow test seems to show esophagus recovered, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253625 - 211021 0715. ref SDS H2 SL57  Aligns with experience having no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253626 - vomiting nor other swallowing deficits past year.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253627 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253628 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253629 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253630 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253631 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253632 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253633 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253635 -  ..
2537 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2538 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2539 - 0947                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2540 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254001 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254002 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254003 - 
254004 - Follow up ref SDS L7 KT9M, ref SDS L2 KT9M.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254006 -  ..
254007 - Doctor Lee presented a digital tablet and requested signature to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254008 - consent for the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254010 -  ..
254011 - Noted that signature is entered on completely black screen, required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254012 - without reading online documents.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254014 -  ..
254015 - Advised that signature is based on following understandings...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254016 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254017 -    1.  CT on 230831 reported...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254018 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254019 -        "Mild apparent distal esophageal wall thickening.  Correlate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254020 -        for any esophagitis." 230831 0800, ref SDS J3 N13S                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254022 -  ..
254023 - Is this evluated with normal examination during EGD procedure?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254025 -  ..
254026 - Actually, this was not discussed today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254028 -         ..
254029 -    2.  Blood Pressure Increased after Taking Pantoprazole 10 years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254030 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254031 -        On 120322 1030 notified Doctor Lee during meeting at VA changed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254032 -        dose for Omeprazole to reduce sudden increase from low to high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254033 -        blood pressure. ref SDS 43 UH5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254035 -         ..
254036 -        Previously, research also indicated omeprazole can cause high blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254037 -        pressure, reported on 101218 1642. ref SDS 32 1J5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254039 -         ..
254040 -        Past 6 - 12 months, seems like blood pressure has been higher                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254041 -        than expected for hiking 20 miles per day.  Had forgotten                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254042 -        prior research on Omeprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254044 -         ..
254045 -        Hiking much lower this year, and past 2 months, which may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254046 -        account for steady rise in blood pressure getting up in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254047 -        morning, see case study on 200101 0701. ref SDS C2 UI8H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254048 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254050 -         ..
254051 -        An article says...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254053 -             ..
254054 -            Research shows proton pump inhibitors may cause cardiovascular problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254055 -            
254056 -            Follow up ref SDS L7 GF6I, ref SDS L2 GF6I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254057 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254058 -              https://www.news-medical.net/news/20130711/Research-shows-proton-pump-inhibitors-may-cause-cardiovascular-problems.aspx                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254060 -             ..
254061 -            In human tissue and mouse models, the researchers found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254062 -            PPIs caused the constriction of blood vessels. If taken                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254063 -            regularly, PPIs could lead to a variety of cardiovascular                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254064 -            problems over time, including hypertension and a weakened                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254065 -            heart. In the paper, the scientists call for a broad,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254066 -            large-scale study to determine whether PPIs are dangerous.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254068 -         ..
254069 -    3.  Ischemic colitis - continues - possibly related to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254070 -        dysfunctional ANS, reported to Doctor Pellegrini, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254071 -        ref SDS L7 VA8H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254072 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254074 -         ..
254075 -    4.  Pantoprazole - there is 1 refill available, so will likely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254076 -        need new new prescription in 1 - 2 months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254078 -         ..
254079 -    5.  Calcium Carbonate - not listed so need new prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254081 -  ..
254082 - Doctor Lee said he will renew all prescriptions today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254084 -         ..
254085 -    6.  Voice continues scratchy about the same following examination                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254086 -        and recommendations by Doctor Lee during EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254087 -        190917 0730. ref SDS C0 HE9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254089 -         ..
254090 -        Voice worse past few weeks, even when concentrating on washing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254091 -        throat with carbonated beverage after each bite of food during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254092 -        meals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254094 -         ..
254095 -        Voice overall better after recent increase dilating LESV to 20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254096 -        mm has improved swallowing, compared to prior practice dilating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254097 -        to only 18 mm.  This has also improved voice function.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254099 -  ..
254100 - Asked Gracie about my voice today.  She said voice seems little                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254101 - scratchy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254103 -  ..
254104 - Doctor Lee concurred voice diminished worse this morning, than it has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254105 - been in the past.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254107 -  ..
254108 - On 180924 0900 meeting with Doctor Summana Jothi at VA Clinic in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254109 - Martinez, determined larynx has slight opening, not enough to cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254110 - occasinoal pronounced scratchy voice.  Reported caused by saliva                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254111 - becoming backed up, because cannot go through LESV ref SDS A6 OL5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254112 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254113 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254115 -         ..
254116 -    7.  Autonomic Nervous System (ANS) Dysfunctional See letter to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254117 -        Doctor Pellegrini on 250127 0813. ref SDS L5 NJ3Q and citing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254118 -        significantly increased varying heart rates reported by Kardia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254119 -        EKGs last year and continuing this year after the 6th cardiac                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254120 -        ablation on 240611 0930. ref SDS K5 RX9J  ANS was initially                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254121 -        considered on 250114 1202. ref SDS L3 JG9G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254123 -         ..
254124 -        Symptoms, per above reported to Vince for entering progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254125 -        notes, ref SDS 0 VA8H, include...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254126 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254127 -            varying heart rate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254128 -            fatigue                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254129 -            bloating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254130 -            chest pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254131 -            blood pressure elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254132 -            heart rate elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254133 -            fainting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254134 -            hallucinations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254135 -            seizures - loss motor control while hiking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254136 -            fell  during hike on 240924, see case study... 240101 0712, ref SDS J7 PYSX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254137 -            cardiac colitis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254138 -            Hiking declined 90%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254139 -            voice disrutption (could HRV/ANS be factor??)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254141 -               ..
254142 -              On 250211 0830 may need addendum to Comorbidities section                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254143 -              adding the above symptoms. at ref SDS L7 HY9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254145 -               ..
254146 -              On 250211 0830 Progress notes Impression #3 says no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254147 -              obvious anatomic explanation for symptoms of upper                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254148 -              abdominal bloating. ref SDS L7 I58J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254149 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254151 -  ..
254152 - Doctor Lee asked about review with Doctor Pellegrini in Cardiology?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254154 -  ..
254155 - Explained...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254156 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254157 -        Letter was submitted to Doctor Pelligrini in Cardiology at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254158 -        VAMCSF on 250114 1202. ref SDS L3 N96F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254159 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254160 -        On 250115 1023 Doctor Pellegrini letter suggested asking Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254161 -        Lee in GI Clinic about possible causes of bloating related to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254162 -        Achalasia. ref SDS L4 H480                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254164 -         ..
254165 -        On 250127 0813 submitted letter with link to EKGs online,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254166 -        ref SDS L5 N96F, asked about varying heart rate and symptoms                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254167 -        indicating dysfunction autonomic nervous system (ANS) causing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254168 -        severe cardiac colitis and other symptoms, e.g., voice fatigue,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254169 -        ref SDS L5 8Y5L, and asking about scheduling tests for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254170 -        dysfunctional ANS, when I am at the hospital on 250207 for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254171 -        meeting in Podiatry. ref SDS L5 NJ40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254173 -         ..
254174 -        On 250206 1818 letter asks Doctor Pellegrini about testing for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254175 -        dysfunctional ANS causing varying heart rate), when on site at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254176 -        VA tomorrow on 250207, to visit Doctor Tang in Podiatry.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254177 -        ref SDS L6 N96F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254179 -         ..
254180 -        During the meeting with Doctor Pelligrini on 240905, we                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254181 -        discussed Kardia mobile EKGs reporting more variable heart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254182 -        rates despite not reporting AFL. These EKGs are taken in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254183 -        morning, and during stops every 5 - 10 miles when hiking.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254184 -        record documents increased arrhythmias...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254185 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254186 -             Arrhythmia Trend Analysis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254187 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254188 -           2500       EKGs   Arymia          Hikes  Miles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254189 -        Jan - Mar       42     32    76%        6     93                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254190 -        Apr - Jun        0      0     0%        0      0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254191 -        Jul - Sep        0      0     0%        0      0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254192 -        Oct - Dec        0      0     0%        0      0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254193 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254194 -           2400       EKGs   Arymia          Hikes  Miles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254195 -        Jan - Mar      198     47    23%       43    983                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254196 -        Apr - Jun      234     95    40%       45    882                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254197 -        Jul - Sep      147     79    53%       23    407                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254198 -        Oct - Dec      142     74    52%       15    271                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254199 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254200 -           2300       EKGs   Arymia          Hikes  Miles                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254201 -        Jan - Mar      246     53    21%       51    948                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254202 -        Apr - Jun      268     90    33%       38    760                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254203 -        Jul - Sep      265     81    30%       52    915                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254204 -        Oct - Dec      251     83    33%       51    888                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254205 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254207 -  ..
254208 - Doctor Lee said he is familiar with dysfunctional ANS, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254209 - ref SDS L7 6H8N  He asked where bloating is most prominent?  Said the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254210 - upper abdomen.  The doctor examined stomach for bloating, pressing on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254211 - upper region of stomach, where bloating most prominent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254213 -  ..
254214 - He will look for signs during the EGD dilation procedure today, of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254215 - digestion issues that may be causing bloating.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254217 -  ..
254218 - Need to know of any digestion issues that may be driving bloating.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254219 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254220 -            [On 250214 0842 called GI Clinic at VAMC Sacramento, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254221 -            asked for Doctor Lee to call with findings on bloating from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254222 -            examination today. ref SDS L8 SK7G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254224 -  ..
254225 - Doctor Lee spoke for a moment with Hazel and I burpped.  He asked if                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254226 - this commonly occurs to relieve bloating, and I said yes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254228 -         ..
254229 -    8.  Fundoplication failing, causing continual stricture of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254230 -        requiring frequent dilation.  Doctor planned to research this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254231 -        issue during meeting on 171115 1142. ref SDS 94 XA4F  Discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254232 -        again during meeting on 180124 1130. ref SDS 97 CT56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254234 -         ..
254235 -        On 180627 1300 Doctor Patel seemed to say GI Clinic at VAMCSF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254236 -        has investigated viability of gastroscope fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254237 -        procedures.  He seemed to further advise that the clinic has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254238 -        referred patients for gastroscope full fundoplication, but not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254239 -        to repair fundoplication. ref SDS A2 JX9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254241 -         ..
254242 -        We reviewed the record in this case that Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254243 -        performed Dor fundoplication on on 091216, as shown Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254244 -        Notes received on 100928 0706. ref SDS 26 VK8F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254246 -         ..
254247 -        At tht time on 180627 1300 asked Doctor Patel to review with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254248 -        the GI team prospects to repair Dor Fundoplication in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254249 -        reduced reflux that continually causes stricture that closes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254250 -        down LESV, requiring repeated EGD dilations on close intervals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254251 -        ref SDS A2 HP4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254253 -         ..
254254 -        Discuss with Samantha Southi developing proposal for using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254255 -        gastroscope to reposition Dor fundoplication for enhanced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254256 -        reflux control.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254258 -  ..
254259 - Did not discuss today, because seem to be managing reflux well enough                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254260 - to minimize formation of stricutre, so that swallowing is not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254261 - impaired, thus avoiding vomiting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254262 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254263 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254265 -         ..
254266 -    9.  Hiatal Hernia - can this subside or otherwise improve over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254267 -        time with any action by patient, similar to ulceration of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254268 -        recovering by ending naproxen, and adding carbonated beverage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254269 -        to washout esophagus during meals?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254271 -         ..
254272 -        What drives worsening of hiatal hernia?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254274 -  ..
254275 - Doctor Lee explained this condition worsens with swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254276 - difficulty.  Since swallowing has been good the past 6 months, he may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254277 - observe improvement in the hiatal hernia during EGD examination today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254278 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254279 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254281 -         ..
254282 -   10.  Dilation 18 - 20 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254284 -  ..
254285 - Today, Doctor Lee reported dilation 16 to 19.5 see below. ref SDS K7                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254286 - 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254287 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254289 -         ..
254290 -   11.  Conscious Sedation with versed - asked Doctor Lee to limit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254291 -        injection of versed to 3 mg, if feasible.  In no case do not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254292 -        exceed 5 mg, in order to avoid stroke symptoms on 160617 1637,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254293 -        ref SDS 77 5F6F, following EGD earlier that day when procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254294 -        took 30 minutes, 100% longer, and so versed was increased to 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254295 -        mg, reported on 160617 0800, ref SDS 76 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254297 -  ..
254298 - This was discussed with Doctor Lee.  He expects EGD will be completed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254299 - with 2 mg versed again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254301 -  ..
254302 - Actually took 3, which is safe.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254303 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254304 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254305 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254306 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254308 -  ..
254309 - OR EGD Dilation with Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254310 - EGD Dilation Procedure in OR Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254311 - 
254312 - Follow up ref SDS L7 T25I, ref SDS L2 T25I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254313 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2546 - 1050                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254701 -  ..
254702 - Mimi is nurse in the room today, and dressed in patient protection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254703 - equipment to avoid spread of coronavirus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254705 -  ..
254706 - Mimi set blood pressure cuff and EKG probes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254708 -  ..
254709 - Mimi connected sensors to monitor vitals.  She connected IV to saline                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254710 - drip, ready to apply conscious sedation drugs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254712 -  ..
254713 - HR monitor showed varying HR - 51 62 71 58 54 67...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254715 -  ..
254716 - This aligns with report by nurse who did vitals prior to meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254717 - Doctor Pellegrini in Cardiology at VAMCSF on 240905 0830. ref SDS K6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254718 - S54I, and further similar to nurse reporting on HR prior to meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254719 - with Doctor Ianuzzi in Vascular Surgery, reported on 240917 1030.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254720 - ref SDS K9 WR4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254722 -  ..
254723 - Mia was the technician.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254725 -  ..
254726 - Everything went smoothly in the OR today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254727 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254729 -  ..
2548 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2549 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2550 - 1019 - Time Out                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
2551 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255101 - Mimi handed a small cup with lidocaine to gargle for 10 seconds.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255103 -  ..
255104 - While Doctor Lee was in the OR with Mimi and the Tech, Mia, reviewed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255105 - again objective to limit versed to 3 mg, and in no case exceed 5 mg,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255106 - in order to avoid causing a stroke, as occurred previously when                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255107 - patient received 6 mg of versed, as agreed in signing Consent for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255108 - procedure today, per above. ref SDS L7 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
255110 -  ..
255111 - Mimi placed a bite block and oxygen nose feed for the procedure.  Did                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255112 - not seem like she covered the face as done for procedures during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255113 - cornavirus pandemic the past few years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255115 -  ..
255116 - Using the catheter, which Gracie set earlier in Preparation, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255117 - above, ref SDS L7 JA4N, Mimi applied Fentanyl, then Benadryl and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255118 - finally versed for conscious sedation.  She laughed saying "Bye Bye,"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255119 - which I had requested for slight humor in the op.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
255121 -  ..
255122 - The team then did the EDG/dilation procedure with Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255124 -  ..
255125 - Gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
255126 - Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
255127 - Start Time........... 1030                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
255128 - Procedure Stop....... 1054                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
255130 -  ..
255131 - Time for procedure...... 24 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255132 -                          --                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
255133 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255134 -     This is longer time than for usual procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
255135 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255137 -  ..
255138 - Nursing Procedural Sedation & Analgesia Flow Sheet Record - Page 1 of 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
255139 - Versed total................   3 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255140 - Fentanyl total.............. 150 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255141 - Benadryl....................  50 ML - 20 last time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
255142 - Lidocaine...................   5 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255143 - IV Fluids normal saline.....     ML  no report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
255144 - Triamcinalone 5 injections..   0.25 mL injected x6 tears - see therapy below. ref SDS L7 F37J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255145 - Saline...................... 200 ML ??                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255147 -  ..
255148 - During procedure while asleep...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255150 -  ..
255151 - Blood pressure 180/90 to  95/85  Heart Rate 70 - 42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255152 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255153 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
255155 -  ..
255156 - Nurses note unreadable.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255158 -  ..
255159 - EKG shows patient in sinus...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255160 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255161 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
255162 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255163 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255165 -  ..
255166 - LESV Contact 0 MM Dilation 19.5 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255167 - Meeting Doctor Lee EGD Dilation 19.5 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
255168 - Ulceration Resolved Meeting Doctor Lee EGD Dilation 19.5 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
255169 - 
255170 - Follow up ref SDS L7 5H5J, ref SDS L2 5H5J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255171 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255173 -  ..
2552 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2553 - 1140                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2554 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255401 - Woke in recovery see Nursing Post-procedure care record.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
255402 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255403 - Gracie assisted.  Other nurses came by to say hello.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255405 -  ..
255406 - IV removed and dressed at 1147                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
255408 -  ..
255409 - Blood pressure 110/70 to 165/95  Heart Rate 50 - 60                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255410 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255411 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
255412 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255413 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255414 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255415 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255417 -  ..
2555 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2556 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2557 - 1150                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2558 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255801 - Doctor Lee indicated that achalasia has stabalized causing significant                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255802 - swallowing problems within 2 months of a procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255804 -  ..
255805 - LESV contracted to 18 mm from 19.5 mm dilated during the last                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255806 - procedure 2 months ago on 250211 0830. ref SDS L7 4Q6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
255808 -  ..
255809 - This was notably better condition compared to prior few EGDs, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
255810 - continued better than severe weekly contractions during 160816 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
255811 - 170905, shown in case study below. ref SDS K3 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
255813 -  ..
255814 - The doctor further advised there was no evidence found of ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255815 - on LESV, which was a concern after resuming use of Naproxen to manage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255816 - pain and inflammation during hiking.  Naproxen has since been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255817 - stopped, as it may have contributed to colitis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255819 -  ..
255820 - Doctor Lee explained dilating the baloon from 18 mm to 19.5 mm.  At                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
255821 - that point, the baloon caused a slight tear in LESV tissue.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255822 - therefore did not dilate to 20 mm, as was done for 5 years, beginning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255823 - on 181002 0800. ref SDS A7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255825 -  ..
255826 - There was slight bleeding from small break in LESV tissue.  He wants                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255827 - to continue Mylanta to be last medication taken before sleeping, so it                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255828 - will coat the tear area and treat it to heal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
255830 -  ..
255831 - Versed was increased slightly today, to 3 mg - still well below 5 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
255832 - maximum, as discussed during the "Time Out" meeting before the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
255833 - procedure, per above. ref SDS L7 639M and ref SDS L7 KL7O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255835 -  ..
255836 - The doctor indicated current medication and eating regimen, per above,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255837 - ref SDS L7 FV8H, should continue to maintain recovery from prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
255838 - achalasia difficulties, i.e., work today demonstrated strong response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255839 - to treatment recovering from achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255841 -  ..
255842 - Triamcinalone was injected to help heal the tear and maintain LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
255843 - dilation.  Amount is noted in progress notes, see below.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
255845 -  ..
255846 - Apparently no biopsies were taken during this procedure today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
255848 -  ..
255849 - Doctor Lee did not explain findings from examination and doing the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
255850 - procedure to resolve bloating issue that has been continuous the past                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
255851 - several months, and discussed last week with Doctor Pelligrini on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
255852 - 240905.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
255853 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255854 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255855 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255856 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255857 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255858 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2559 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 L7 XM3J, ref SDS L2 XM3J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260406 - Today, was achalasia procedure #72                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
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 -          2     250408   40  160     18     19.5..100.0.....3......50......150.....04.... ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260415 -          2     250211   40  160     18     19.5..100.0.....3......50......150.....04.... ref SDS L7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260416 -          2     241126   40  160     15     19....100.0.....2......50......150.....04.... ref SDS L2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260417 -          4     240910   40  160     15     19....100.0.....2......50......150.....04.... ref SDS K7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260418 -          4     240507   40  160     15     18....100.0.....2......50......150.....04.... ref SDS K3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260419 -          4     240116   40  160     18     19....100.0.....3......50......200.....04.... ref SDS J8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260420 -          6     230908   40  160     18     18....100.0.....3......50......200.....04.... ref SDS J5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260421 -          6     230303   40  160     19     20....100.0.....3......50......150.....04.... ref SDS I9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260422 -          6     220805   40  160     19     20....100.0.....3......50......150.....04.... ref SDS I3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260423 -          5     220204   40  160     18     20....100.0.....3......50......200.....04.... ref SDS H8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260424 -          6     210905   40  160     18     20......0.0.....3......50......150.....04.... ref SDS G8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260425 -          4     210305   40  160     19     20......0.0.....3......50......150.....04.... ref SDS G6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260426 -          2     201106   40  160     20     20......0.0.....3......50......150.....04.... ref SDS F9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260427 -          2     200908   40  160     19     20......0.0.....2......50......100.....10.... ref SDS F2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260428 -          2     200707   40  160     19     20......0.0.....2......50......100.....10.... ref SDS E6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260429 -          2.5   200529   40  160     19     20......0.0.....2......50......100.....10.... ref SDS D4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260430 -          2     200310   40  160     19     20......0.0.....3......50......150.....10.... ref SDS C8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260431 -          2     200110   40  160     19     20......0.0.....3......50......150.....10.... ref SDS C6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260432 -          2     191112   40  160     19     20......0.0.....3......50......150.....10.... ref SDS C1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260433 -          1     190917   40  160     19     20......0.0.....3......50......150.....10.... ref SDS C0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260434 -          1     190813   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260435 -          1     190709   40  160     20     20......0.0.....3......50......150.....10.... ref SDS B8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260436 -          1     190618   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260437 -          1     190521   40  160     18     20......0.0.....3......50......200.....10.... ref SDS B6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260438 -          1     190416   40  160     18     20....100.0.....3......50......200.....10.... ref SDS B5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260439 -          1     190319   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260440 -          1     190215   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260441 -          1     190118   40  160     18     20......0.0.....3......50......150.....10.... ref SDS B0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260442 -          1     181218   40  160     18     20......0.0.....4......50......150.....10.... ref SDS B0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260443 -          1     181127   40  160     18     20......0.0.....3......25......250.....10.... ref SDS A9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260444 -          1     181030   40  160     18     20......0.0.....3......25......250.....10.... ref SDS A8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260445 -          1     181002   40  160     18     20......0.0.....3......25......250.....10.... ref SDS A7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260446 -          1     180904   40  160     16.5   19......0.0.....3......25......250.....10.... ref SDS A5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260447 -          1     180814   40  160     16     19......0.0.....3......25......250.....10.... ref SDS A4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260448 -          0.5   180713   40  160     16.5   18......0.0.....3......25......250.....10.... ref SDS A3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260449 -          2.5   180627   40  160     12     16.5....0.0.....3......25......250.....10.... ref SDS A1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260450 -          2     180417   40  160     16.5   19......1.0.....3......25......250.....10.... ref SDS 99 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260451 -          1.50  180227   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS 98 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260452 -          1.25  180109   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS 96 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260453 -          1     171128   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS 95 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260454 -          2     171031   40  160     15.5   18......1.0.....4......25......250.....10.... ref SDS 93 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260455 -          1.53  170905   80   80     15     18......1.0.....3......25......250.....10.... ref SDS 92 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260456 -          1.53  170516   80   80     16.5   19......1.0.....5......25......250.....10.... ref SDS 91 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260457 -          1.53  170404   80   80     16.5   18......1.5.....5......25......200.....10.... ref SDS 90 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260458 -          1.53  170221   80   80     15     18......2.0.....5......25......200......5.... ref SDS 89 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260459 -          0.80  170106   80   80     16.5   18......2.0.....5......25......200......5.... ref SDS 88 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260460 -          0.23  161213   80   80     15     18......3.0.....5......25......200......5.... ref SDS 87 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260461 -          0.20  161206   80   80     11     16.5....1.0.....5......25......200......5.... ref SDS 86 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260462 -          0.27  161130   80   80     11     15......0.0.....5......25......200......5.... ref SDS 84 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260463 -          0.23  161122   80   80      6     12......0.0.....5......25......200......5.... ref SDS 82 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260464 -          1.40  161115   42   80     10     10......0.0.....5......25......200......5.... ref SDS 81 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260465 -          0.83  161004   26   80     11     15......5.0.....5......25......200......5.... ref SDS 80 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260466 -     *1   0.80  160909   80    0     10     15......5.0.....5......25......200......5.... ref SDS 79 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260467 -          2     160816   11   40      9.5   10......5.0.....4......50......150......5.... ref SDS 78 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260468 -          3     160617   10   40      9.5   15......5.0.....6......50......250......5.... ref SDS 76 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260469 -     *2   3     160315   15   40      9.5   15......3.0.....5......25......250......5.... ref SDS 75 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260470 -          8     151204   32   20     10     15......5.0.....5......25......200......5.... ref SDS 72 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260471 -     *3   6     150421   41          16.5   18......3.0.....4......50......250......5.... ref SDS 62 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260472 -          6     141107   37          15     18......4.0.....5......50......150......5.... ref SDS 59 E54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260473 -          6     140509   24          16.5   18..............5......50......200......5.... ref SDS 53 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260474 -     *4   7     131115   24          16.5   18......2.0.....4......50......200......5.... ref SDS 47 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260475 -          3     130416   38          18     18......2.0.....5......50......250......5.... ref SDS 46 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260476 -          4     130110   39          15     18......3.0.....4......50......100......5.... ref SDS 45 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260477 -     *5   6     120925   38          15     18......4.0.....5......50......200......5.... ref SDS 44 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260478 -     *6   4     120322   27          16.5   18..............4......50......150......5.... ref SDS 42 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260479 -     *7   3     111115   76          16.5   18..............4......50......200......5.... ref SDS 39 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260480 -          4     110819   80          15     16.5....2.5.....5......50......200......5.... ref SDS 38 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260481 -          2     110429   80          13     16.5....3.5.....5..............200......5.... ref SDS 35 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260482 -          2     110218   80          11     14......2.0.....4......50......150......5.... ref SDS 34 SS5R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260483 -          4     101210   40          11     14......................................5.... ref SDS 30 BF6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260484 -          6     100827    4          11     15..............5......50......250......5.... ref SDS 25 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260485 -          3     100305    0          11     15..............5......50......250......5.... ref SDS 24 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260486 -          -     091216               Heller Myotomy Fundoplication................. ref SDS 22 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260487 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260489 -         ..
260490 -     ** Dates are from case study on exercise, diet, vitals and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260491 -        medication, shown on 160101, ref SDS 74 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260492 -        previously on 140101. ref SDS 50 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260493 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260494 -     *1 On 160911 paused Pantoprazole to reduce dehydration through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260495 -        frequent urination until after Half Dome, and resumed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260496 -        160920.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260497 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260498 -     *2 On 151210 begin Omeprazole 20 mg every other day. ref SDS 50 E64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260499 -        Resumed Omeprazole 20 mg on 160323. ref SDS 74 RSXR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260501 -         ..
260502 -        On 150924 hospitalized hematoma debridement; begin Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260503 -        20 mg per day. ref SDS 50 JT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260505 -     *3 On 150920 about 5 attacks convulsions, nausea not taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260506 -        Omeprazole - took 40 mg. ref SDS 50 656M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260508 -     *4 On 131115 Doctor Lee prescribed Omeprazole 40 mg 1 month then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260509 -        20 mg for next 5 months. ref SDS 47 ZY5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260511 -         ..
260512 -     *5 On 130106, 4 days before EGD on 130110, reduced Omeprazole to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260513 -        20 mg per day, shown in case study on 120101 0900, ref SDS 41                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260514 -        AD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260515 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260516 -     *6 On 120907 Doctor Egan research found Omeprazole increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260517 -        blood pressure, sensed possible correlation patient sudden                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260518 -        rise in blood pressure, recommended reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260519 -        to 20 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260521 -     *7 On 11115 Doctor Lee prescribed continue PPI 80 mg; on 111201,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260522 -        patient reduced dose to 20 mg on record of rising blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260523 -        pressure despite increased hiking; research indicated PPI may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260524 -        elevate blood pressure, see case study 101010 0744, ref SDS 27 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260525 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260528 -  ..
260529 - Conscious Sedation Increased Dose Applied for 24 Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260530 - 
260531 - Follow up ref SDS L7 714N, ref SDS L2 714N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260533 - Nursing Procedural Sedation & Analgesia Flow Sheet Record Page 1 shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260534 - versed 3 ML, even though the procedure took 24 minutes, per above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260535 - ref SDS L7 UT4N  Limiting versed to 3 mg, aligned with discussion prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260536 - to starting the procedure, per above, ref SDS L7 KL7O,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260538 -  ..
260539 - No post procedure side effects as occurred previously on 161213 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260540 - ref SDS 87 R74J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260542 -  ..
260543 - Seem sleepy even hours after the procedure using 3 ml versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260546 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260547 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260549 -  ..
260550 - Ulceration on Esophagus Above LESV Significantly Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260551 - 
260552 - Follow up ref SDS L7 RZ3G, ref SDS L2 RZ3G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260553 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260554 - Doctor Lee reported this morning that EGD procedure found that both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260555 - ulcerations on the side of esophagus above LESV continue to be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260556 - completely resolved, reported following EGD on 190917 0730.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260557 - ref SDS C0 RZ3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260559 -  ..
260560 - The doctor said the small ulceration found during procedure 16 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260561 - ago, continues completely resolved today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260563 -  ..
260564 - Triamcinalone was injected in 5 locations to aid healing of small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260565 - tears during dilation, and to maintain dilation opening diameter - see                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260566 - case study above. ref SDS K3 YR4H  Not sure of the amount.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260568 -  ..
260569 - Doctor Lee did not have time to present pictures showing improved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260570 - condition with reduced ulceration of LESV, following EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260571 - procedure today, per above. ref SDS K3 OM7J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260573 -  ..
260574 - Doctor Lee did not explain plans to further research continuing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260575 - pentoprazole everyday before dinner for next 2 months, and to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260576 - prescribe a new PPI that does not raise blood pressure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260577 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260578 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260579 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260580 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260582 -  ..
260583 - Discharge Instructions and Schedule Next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260584 - Schedule Next Procedure and Post Procedure Review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260585 - 
260586 - Follow up ref SDS L7 XF6X, ref SDS L2 XF6X.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260587 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260588 - Doctor Lee feels results today, show achalasia LESV stable at worse                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260589 - condition than past 5 years.  He scheduled next procedure in 2 months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260591 -  ..
260592 - Jolie called the next day on 250409 1000, and scheduled next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260593 - dilation on...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260594 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260595 -                          250718 0830                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260597 -  ..
260598 - Discharge Instructions...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260599 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260600 -         Dilation.... 16..... 19.5  (small tear) Triamcinalone injection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260601 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260602 -         Repeat EGD in 2 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260603 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260604 -         Continue carbonated drinks to clear throat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260606 -          ..
260607 -         Things to remember after receiving sedation?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260609 -            1.  Do not drive a car.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260610 -            2.  Do not drnk alcohol                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260611 -            3.  Do not operate heavy machinery or power tools                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260612 -            4.  Do not sign legal or financial documents                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260613 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260615 -  ..
2607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2609 - 1202                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2610 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
261001 - Discharge                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
261002 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261003 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261004 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261005 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261006 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261007 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2611 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

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 L7 Q05K, ref SDS L2 Q05K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270419 -  ..
270420 - Stored Progess Notes for procedure on 250211 at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270421 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270422 -              F:\05\00003\SM\CC\AGMJ\20250211-083000\mhv_WELCH_20250214_1909.txt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270424 -  ..
270425 - File may require password... 03011945 (birthday)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270426 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270428 -  ..
270429 - This file did not include photographs taken during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270430 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270431 -        Sacramento VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270432 -        10535 Hospital Way Mather CA, 95655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270434 -  ..
270435 - Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270437 -         ..
270438 -        Date/Time:               11 Feb 2025 @ 1729                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270439 -        Note Title:              EGD Procedure Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270440 -        Location:                No CA Healthcare Sys-Martinez                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270441 -        Signed By:               CLINICAL,DEVICE PROXY SERVICE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270442 -        Date/Time Signed:        11 Feb 2025 @ 1729                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270444 -         ..
270445 -        LOCAL TITLE: EGD Procedure Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270446 -        STANDARD TITLE: GASTROENTEROLOGY DIAGNOSTIC STUDY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270447 -        DATE OF NOTE: FEB 11, 2025@17:29:15  ENTRY DATE: FEB 11, 2025@17:29:15                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270448 -        AUTHOR: CLINICAL,DEVICE PRO  EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270449 -        URGENCY:                           STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270450 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270451 -        ** DOCUMENT IN VISTA IMAGING **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270452 -        SEE FULL REPORT IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270454 -         ..
270455 -        SIGNATURE NOT REQUIRED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270456 -        SEE SIGNATURE IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270457 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270458 -        ** (PROVATION EGD)  AUTO-INSTRUMENT DIAGNOSIS **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270460 -         ..
270461 -        Procedure: ExamEndo  Upper GI endoscopy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270463 -         ..
270464 -        Release Status: Released Off-Line Verified                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270465 -        Date Verified: Feb 11, 2025@17:29:08                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270467 -         ..
270468 -        VA Mather                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270469 -        GI                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270471 -        Procedure Date: 2/11/2025 9:16 AM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270475 -        Age: 79                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270476 -        Procedure:             Upper GI endoscopy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270477 -        Indications:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270478 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270479 -            Dysphagia: 79 yo man with achalasia and post-myotomy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270480 -            recurrent GERD stricture since 2010. Last dilated to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270481 -            19mm 11/2024. Here for maintenance dilation. No                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270482 -            interim worsening of dysphagia. Has primary care,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270483 -            cardiology, podiatry care at SFVA. Has recurrent upper                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270484 -            abdominal bloating relieved by belching. Also notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270485 -            heart rate variation. Questions if this may be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270486 -            autonomic nervous system dysfunction.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270488 -         ..
270489 -        Comorbidities                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270490 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270491 -             hx CAD, s/p CABG; recurrent atrial flutter, s/p ablation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270492 -             therapy x 6.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270494 -  ..
270495 - Comorbidities may need to include symptoms reported to Gracie this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270496 - morning, per above. ref SDS L7 VA8H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270497 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270499 -         ..
270500 -        Patient Profile:  Refer to note in patient chart for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270501 -                          documentation of history and physical.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270503 -         ..
270504 -        Providers:        Randall E. Lee, MD (Doctor), Mimi Terrado, RN,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270505 -                          Mai Pa Zor Her, Technician                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270507 -         ..
270508 -        Referring MD:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270509 -        Requesting Provider:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270511 -         ..
270512 -        Medicines:        Midazolam 3 mg IV, Fentanyl 150 mcg IV,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270513 -                          Diphenhydramine 50 mg IV, O2 [40]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270514 -                          LPM High Flow Nasal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270516 -         ..
270517 -        Complications:    No immediate complications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270519 -         ..
270520 -        Procedure:             Pre-Anesthesia Assessment:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270521 -                               - Prior to the procedure, a History and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270522 -                               Physical was performed, and patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270523 -                               medications and allergies were reviewed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270524 -                               The patient's tolerance of previous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270525 -                               anesthesia was also reviewed. The risks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270526 -                               and benefits of the procedure and the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270527 -                               sedation options and risks were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270528 -                               discussed with the patient.  All                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270529 -                               questions were answered, and informed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270530 -                               consent was obtained.  Prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270531 -                               Anticoagulants: The patient has taken no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270532 -                               anticoagulant or antiplatelet agents.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270533 -                               After reviewing the risks and benefits,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270534 -                               the patient was deemed in satisfactory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270535 -                               condition to undergo the procedure. -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270536 -                               Prior Aspirin/ NSAID therapy:  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270537 -                               patient has taken no aspirin or NSAID                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270538 -                               medications.  After obtaining informed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270539 -                               consent, the endoscope was passed under                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270540 -                               direct vision.  Throughout the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270541 -                               procedure, the patient's blood pressure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270542 -                               pulse, and oxygen saturations were                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270543 -                               monitored continuously.  The 9469 GIF-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270544 -                               HQ190 was introduced through the mouth,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270545 -                               and advanced to the third part of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270546 -                               duodenum.  The upper GI endoscopy was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270547 -                               accomplished with ease. The patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270548 -                               tolerated the procedure well.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270550 -                                ..
270551 -                               Start time: 1030                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270552 -                               End time: 1054                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270553 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270555 -         ..
270556 -        Findings:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270557 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270558 -            The hypopharynx was normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270559 -            The proximal esophagus was dilated and aperistaltic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270560 -            The mid esophagus was dilated and aperistaltic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270561 -            The lower third of the esophagus was dilated and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270562 -            aperistaltic. A tattoo at 31cm was again identified, but no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270563 -            associated mass.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270564 -            Esophagogastric landmarks were identified: the lower esophageal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270565 -            sphincter was found at 38 cm from the incisors. This was mildly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270566 -            strictured with an estimated diameter of 18mm. No erosions or ulcers.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270567 -            The cardia was normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270568 -            The gastric fundus was normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270569 -            The gastric body was partially plicated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270570 -            The gastric antrum was normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270571 -            The pylorus was normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270572 -            The duodenal bulb was normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270573 -            The second portion of the duodenum was normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270574 -            The ampulla was normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270575 -            The third portion of the duodenum was normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270577 -             ..
270578 -            Therapy:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270579 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270580 -            1.  TTS balloon positioned across LES.  Inflated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270581 -                18mm-19mm-19.5mm sequentially with interval pressure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270582 -                stabilization. (+) mucosal tear from 18mm to 19mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270584 -                 ..
270585 -            2.  Triamcinolone acetate 20mg/mL, 0.25mL x6 injected into                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270586 -                mucosal tears.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270588 -         ..
270589 -        Impression:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270590 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270591 -            1.  Mild reduction in esophageal lumenal diameter, but                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270592 -                no evidence of uncontrolled reflux (no erosions or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270593 -                ulcer).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270594 -            2.  Absence of erosions/ulcers suggests GERD continues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270595 -                to be well controlled on current regimen of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270596 -                proton-pump inhibitor + H2RA + antacid therapy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270597 -            3.  No obvious anatomic explanation for symptoms of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270598 -                upper abdominal bloating.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270600 -  ..
270601 - Is #3 the same as saying examination today, found no evident GI cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270602 - for symptom of autonomic nervous system dysfunction, responding to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270603 - Cara Pellegrini's inquiry on 250115 1023. ref SDS L4 H480                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270604 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270605 -            [On 250218 0810 Doctor Lee called and confirmed that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270606 -            bloating is caused by GI issue. ref SDS L9 D16O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270608 -             ..
270609 -            [On 250226 1048 letter to medical team, including Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270610 -            Pellegrini notifies that Doctor Lee made examination on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270611 -            250211, and found no anatomic explanation for bloating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270612 -            occuring following cardiac ablation on 240611. ref SDS M0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270613 -            5H93                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270614 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270616 -         ..
270617 -        Recommendation:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270618 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270619 -            - Repeat EGD + dilation about 2 months. RTCO entered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270620 -            - Continue current regimen of proton-pump inhibitor,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270621 -            supplemented by H2RA and antacid.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270622 -            - At patient's request inquire about testing for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270623 -            dysautonomia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270624 -            - The patient is not currently taking anticoagulant or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270625 -            antiplatelet agents and therefore does not require                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270626 -            instructions for their resumption.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270627 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270629 -         ..
270630 -        Randall E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270631 -        Randall E. Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270632 -        2/11/2025 5:29:06 PM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270633 -        Number of Addenda: 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270634 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270636 -         ..
270637 -        Administrative Closure: 02/11/2025                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270638 -                             by:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270639 -                                 CLINICAL,DEVICE PROXY SERVICE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
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2707 -