CONTACTS 

SUBJECTS
Endoscopy Colonoscopy Test Follow Up Complications None Reported Med

4803 -
4803 -    ..
4804 - Summary/Objective
4805 -
480501 - Follow up ref SDS 49 0000. ref SDS 48 0000.
480502 -
480503 -
480504 -
480505 -
480507 -  ..
4806 -
4807 -
4808 - Background
4809 -
480901 - Background on endoscopy and colonoscopy tests reported on 100305 1000.
480902 - ref SDS 48 5R5H
480904 -  ..
480905 - On 100312 1119 got in the car and drove to the VA in Martinez, about
480906 - 20 miles away, and received documents on health care from 100301 to
480907 - 100312. ref SDS 0 MN4O
480908 -
480910 -  ..
4810 -
4811 -
4812 - Progress
4813 -
481301 - Confidentiality Health Records Provents Identify Theft Embarrassement
481302 -
481303 - Implemented Marcia's recommendation to get in the car and drive 20
481304 - miles to the VA for the record on recent work, instead of VA
481305 - transmitting the record electronically to save time and money by
481306 - containing health care costs, which was requested during the meeting
481307 - at the VA on 100305 1000. ref SDS 48 HB4K
481309 -  ..
481310 - Met with Wilma in the Release of Information Department, and received
481311 - the following...
481312 -
481313 -    1.  Department of Veterans Affairs
481314 -        Martinez VA Outpatient Clinic
481315 -        150 Muir Road
481316 -        Mail Stop:  ROI/MTZ
481317 -        Martinez, CA  94553
481319 -         ..
481320 -    2.  Date:  March 12, 2010
481321 -
481322 -        In Reply Refer To:  ROI/MTZ
481329 -         ..
481330 -    3.  Subject: ROI Request for...
481337 -         ..
481338 -    4.  This individually identifiable information is priveleged.  Its
481339 -        confidentiality should be maintained along with appropriate
481340 -        security safeguards to protect against individual harm
481341 -        (identify theft), embarrassemnt, or inconvenience.
481343 -  ..
481344 - Purpose of refusal to transmit medical records electronically to
481345 - prevent identify theft can be accomplished by redacting identify
481346 - information, as shown in this record.  Concerns about embarrassment
481347 - occur along a continuum from none to extreme, depending upon what is
481348 - in the record, and the personality of the patient.  Embarrassment, if
481349 - any, must be balanced against advantages of convenience and cost
481350 - containment saving 4 - 8 hours re-typing content that the VA has
481351 - already typed, and getting in the car, expending time, fuel,
481352 - depreciation driving 20 miles to the VA, requiring an outstanding VA
481353 - staff in Release of Information Department expending time and money
481354 - producing printed documents, and driving 20 miles back to begin typing
481355 - something can be achieved in 10 seconds using email, as discussed with
481356 - the doctor on 100305 1000. ref SDS 48 HB4K; and, discussed again with
481357 - Marcia on 100308 1411. ref SDS 49 CH58
481358 -
481359 -            [On 100317 1213 letter to VA commends excellent medical
481360 -            services, and confirms understandings that medical tests on
481361 -            100305 made findings of no cancer, and that acid burn has
481362 -            occurred only on the flap constructed by Doctor Stewart to
481363 -            protect the modified esophgeal sphincter valve from causing
481364 -            acid reflux. ref SDS 50 PT6W
481366 -             ..
481367 -            [On 100331 1448 VA letter seems to expand understandings
481368 -            from meeting on 100305, ref SDS 48 PR6P, and presented in
481369 -            feedback letter to the VA on 100317 1213. ref SDS 50 PT6W,
481370 -            to relate test findings of general reflux esophagitis,
481371 -            rather than or in addition to mere "acid burn" on the flap
481372 -            for the esophageal sphincter valve. ref SDS 51 YW5S
481374 -  ..
481375 - VA Letter Transmitting Medical Records continues...
481376 -
481377 -        Sincerely,
481378 -
481380 -         ..
481382 -        Release of Information
481384 -         ..
481385 -    5.  Enclosures
481386 -
481387 -        1.  Lab Results......................... 100312 1119, ref SDS 0 6U4H,
481389 -             ..
481390 -        2.  Progress Notes
481391 -            GI Post Procedure Phone
481392 -            Call................................ 100308 1411, ref SDS 49 4U9H
481394 -             ..
481395 -        3.  Progress Notes
481396 -            Local Title:  GI Pre-Proc Provider
481397 -            Assmnt 60440
481398 -            Standard Title:  Gastroenterology
481399 -            Procedure Note
481400 -            shown on............................ 100305 1000, ref SDS 48 RQ3K
481402 -             ..
481403 -        4.  Progress Notes
481404 -            Local Title:  GI Nurse Pre-Proc
481405 -            Checklist 60439
481406 -            Standard Title:  Gastroenterology
481407 -            Nursing Procedure Note
481408 -            shown on............................ 100305 1000, ref SDS 48 P86K
481410 -             ..
481411 -        5.  Plan of Care - Intra-procedure
481412 -            sedation............................ 100305 1000, ref SDS 48 W35M
481414 -             ..
481415 -        6.  Procedure 1
481416 -            Endoscopy Test...................... 100305 1000, ref SDS 48 Y65G
481418 -             ..
481419 -        7.  Photographs Endoscopy
481420 -            8 pictures.......................... 100305 1000, ref SDS 48 XI5O
481422 -             ..
481423 -        8.  Procedure 2
481424 -            Colonoscopy Test.................... 100305 1000, ref SDS 48 PG6G
481426 -             ..
481427 -        9.  Photographs Colonoscopy
481428 -            4 pictures.......................... 100305 1000, ref SDS 48 F48I
481429 -
481431 -  ..
481432 - Pictures are in black and white, and "acid burn" problem is not marked
481433 - nor otherwise clearly evident, contrary to post-procedure discussion
481434 - at that time on 100305 1000, ref SDS 48 PR6P
481436 -  ..
481437 - Color pictures may more clearly delinate "acid burn" problem, which is
481438 - not otherwise presented in findings for Progress Notes for Endoscopy,
481439 - reported on 100305 1000. ref SDS 48 Y65V
481440 -
481441 -
481442 -
4815 -

SUBJECTS
Default Null Subject Account for Blank Record

4903 -
490401 -  ..
490402 - Lab Results Endoscopy and Colonoscopy Tests
490403 -
490404 - Report sheet of paper beginning page 1 says...
490405 -
490406 -    1.  Printed on March 12, 2010
490407 -
490408 -    2.  Patient Name and Adress (mechanical iprinting if available)
490414 -         ..
490415 -    3.  Vista Electronic Medical Documentation
490416 -        Printed at Martinez OPC/CREC
490418 -         ..
490419 -        Blood Bank
490421 -         ..
490422 -        Legacy Vista Blood Bank Report
490424 -         ..
490425 -    4.  The following historical information comes from the Legacy
490426 -        Vista Blood Bank System.  It represents data collected prior
490427 -        to the installatio of VBECS.  Some of the information in this
490428 -        report may have been duplicated in the VBECS report above (if
490429 -        available).
490431 -         ..
490432 -    5.  Surgical Pathology
490433 -
490434 -        Date Spec taken................. 2010 March 05
490435 -        Date Spec rec'd................. 2010 March 08 1047
490436 -        Date Completed.................. 2010 March 09
490437 -        Pathologist..................... Jimmy Chen MD
490438 -        Resident........................ Michelle McNamara MD
490439 -        Accession #..................... SP 10 1612
490440 -        Submitted by.................... Pratitioner: Randall E Lee MD
490442 -         ..
490443 -    6.  Specimen
490444 -
490445 -        a.  Gastric BX
490446 -        b.  Esophageal BX at 38cm
490447 -        c.  Esophageal BX at 36cm
490448 -        d.  Esophageal BX at 34cm
490449 -        e.  Esophageal BX at 30cm
490451 -         ..
490452 -    7.  Clinical History
490453 -
490454 -        65 y/o man with achalasia S/P myotomy ? maligancy or dysplasia
490456 -         ..
490457 -    8.  Preoperative Diagnosis
490458 -
490459 -        Achalasia
490461 -         ..
490462 -    9.  Operative Findings
490463 -
490464 -        Stricture at 38 cm erythema 36 - 30 cm
490466 -         ..
490467 -   10.  Postoperative Diagnosis
490468 -
490469 -        GERD structure stasis esophagitis
490471 -         ..
490472 -   11.  Gross Description
490473 -
490474 -        a.  Received in formalin, designated "gastric biopsy", and
490475 -            consists of multiple fragments of tan soft tissue measuring
490476 -            in aggregate 0.6 x 0.4 x 0.3 cm.  Tissue is totally
490477 -            submitted in one cassette.
490479 -             ..
490480 -        b.  Received in formalin, designated "esophagus at 38cm" and
490481 -            consists of two fragments of tan soft tissue measuring 0.4
490482 -            x 0.1 x 0.3 cm in aggregate.  Tissue is totally submitted
490483 -            in one cassette.
490485 -             ..
490486 -        c.  Received in formalin, designated "esophagus at 36cm", and
490487 -            consists of multiple fragments of white-tan soft tissue
490488 -            measuring 0.6 x 0.5 x 0.3 cm in aggregate.  Tissue is
490489 -            totally submitted in one cassette.
490491 -             ..
490492 -        d.  Received in formalin, designated "esophagus at 34cm", and
490493 -            consists of multiple minute fragments of tan soft tissue
490494 -            measuring 0.4 x 0.3 x 0.1 cm in aggregate.  Tissue is
490495 -            totally submitted in one cassette.
490497 -             ..
490498 -        e.  Received in formalin, designated "esophagus at 34cm", and
490499 -            consists of multiple fragments of white-tan soft tissue
490500 -            measuring 0.2 x 0.3 x 0.2 cm in aggregate.  Tissue is
490501 -            totally submitted in one cassette. (MM/3-8-10/dd)
490503 -         ..
490504 -   12.  Microscopic examination/diagnosis
490505 -        (Date Spec taken:  2010 March 05)........ ref SDS 0 Q23G
490506 -
490507 -        a.  Stomach, Gastric (biopsy)
490508 -
490509 -            Chronic gastritis
490511 -             ..
490512 -            No evidence of helicobacter pylori is seen with
490513 -            warthin-starry stain
490515 -  ..
490516 - Research finds....
490517 -
490518 -                Emedicinehealth...
490519 -
490520 -                Gastritis Overview...
490521 -
490522 -                    http://www.emedicinehealth.com/gastritis/article_em.htm#Gastritis%20Overview
490524 -                 ..
490525 -                Gastritis, an inflammation or irritation of the lining
490526 -                of the stomach, is not a single disease.  Rather,
490527 -                gastritis is a condition that has many causes.  Common
490528 -                to all people with gastritis is pain or discomfort in
490529 -                the upper part of the belly (abdomen), sometimes called
490530 -                dyspepsia
490532 -                 ..
490533 -                Emedicinehealth...
490534 -
490535 -                    http://www.emedicinehealth.com/script/main/art.asp?articlekey=8285
490537 -                 ..
490538 -                Dyspepsia refers to a condition (disease) in which
490539 -                there are upper abdominal symptoms which may include
490540 -                upper abdominal pain, bloating (a feeling of abdominal
490541 -                fullness without objective abdominal distention), early
490542 -                satiety (a feeling of unusual fullness with very little
490543 -                intake of food), nausea, or belching.  The symptoms
490544 -                often are provoked by eating.
490546 -                 ..
490547 -                Helicobacter pylori is a type of bacteria that infects
490548 -                the stomach. Infection with this bacteria may lead to
490549 -                chronic gastritis.
490551 -  ..
490552 - The analyst may be reporting there is no evidence of gastritis,
490553 - because there is no evidence of helicobacter pylori. ref SDS 0 VY4I
490555 -  ..
490556 - Lab results for biopsy continue...
490557 -
490558 -        b.  Esophagus at 38 cm (biopsy)
490559 -
490560 -               [On 100331 1448 followed up, ref SDS 51 1R6O
490561 -
490562 -            Reflux esophagitis
490563 -
490564 -               [...below see questions on test findings. ref SDS 0 QQ7O
490566 -                ..
490567 -               [On 100331 1448 VA letter seems to expand understandings
490568 -               from meeting on 100305, ref SDS 48 PR6P, and presented
490569 -               in feedback letter to the VA on 100317 1213. ref SDS 50
490570 -               PT6W, to relate test findings of general reflux
490571 -               esophagitis, rather than or in addition to mere "acid
490572 -               burn" on the flap for the esophageal sphincter valve.
490573 -               ref SDS 51 YW5S
490575 -                ..
490576 -               [On 100912 1127 received copy of biopsy with VA
490577 -               transmittal letter, ref SDS 54 1W5I, and Doctor Lee
490578 -               explaining results of endoscopy EGD test findings,
490579 -               and biopsy show no cancer, pre-cancerous tissue, nor
490580 -               infection, but did find acute inflammation, which
490581 -               Doctor Lee describes as severe acid reflux damage.
490582 -               ref SDS 54 TN80, which aligns with findings shown
490583 -               above on 100827 0728, ref SDS 53 JF4Q, and previously
490584 -               described in the biopsy report received on 100312
490585 -               for the EGD on 100305, as "reflux esophagitis."
490586 -               ref SDS 0 MX5K
490588 -             ..
490589 -            No intestinal metaplasia (no Barrett's Esophagus)
490591 -  ..
490592 - Research finds....
490593 -
490594 -                What is Barrett's esophagus?
490595 -
490596 -                    http://www.barrettsinfo.com/content/1_what_is_barretts.cfm
490597 -
490598 -                Barrett's esophagus is a condition in which the normal
490599 -                squamous epithelium of the esophagus has been replaced
490600 -                by an abnormal red columnar epithelium called
490601 -                specialized intestinal metaplasia.  Specialized
490602 -                intestinal metaplasia is red, like normal stomach
490603 -                tissue, but does not look like stomach tissue under the
490604 -                microscope.  Therefore, a biopsy (a piece of tissue
490605 -                taken from the esophagus) is needed to diagnose
490606 -                Barrett's esophagus.
490608 -                 ..
490609 -                The diaphragm (breathing muscle) separates the
490610 -                abdominal cavity from the chest cavity. Normally the
490611 -                entire stomach lies within the abdominal cavity. In
490612 -                this illustration, a small portion of the stomach has
490613 -                moved backwards through the opening in the diaphragm
490614 -                and into the chest cavity. This small portion of
490615 -                stomach above the diaphragm is referred to as a hiatal
490616 -                hernia.
490618 -                 ..
490619 -                Barrett's esophagus is a pre-malignant (precancerous)
490620 -                condition.  This means that the Barrett's lining is
490621 -                more prone to developing cancer than other normal
490622 -                tissues of the body. The type of cancer that develops
490623 -                in Barrett's esophagus is called esophageal
490624 -                adenocarcinoma. Since the 1970's, this cancer has been
490625 -                rapidly increasing in Western Europe and the United
490626 -                States.  Esophageal adenocarcinoma now accounts for
490627 -                60% of all esophageal cancers in the U.S. with an
490628 -                estimated 8,000 new cases diagnosed per year.
490630 -                 ..
490631 -                Barrett's esophagus
490632 -                From Wikipedia, the free encyclopedia
490633 -
490634 -                    http://en.wikipedia.org/wiki/Barrett%27s_esophagus
490636 -                 ..
490637 -                Barrett's esophagus (British English: oesophagus)
490638 -                (sometimes called Barrett's syndrome, CELLO, columnar
490639 -                epithelium lined lower esophagus and colloquially
490640 -                referred to as Barrett's) refers to an abnormal change
490641 -                (metaplasia) in the cells of the lower end of the
490642 -                esophagus  thought to be caused by damage from chronic
490643 -                acid exposure, or reflux esophagitis.
490645 -  ..
490646 - Lab results for biopsy continue...
490647 -
490648 -        c.  Esophagus at 36 cm (biopsy)
490649 -
490650 -            Reflux esophagitis
490651 -
490652 -               [...below see questions on test findings. ref SDS 0 QQ7O
490654 -             ..
490655 -            No intestinal metaplasia (no Barrett's Esophagus)
490657 -             ..
490658 -        d.  Esophagus at 34 cm (biopsy)
490659 -
490660 -            Reflux esophagitis
490661 -
490662 -               [...below see questions on test findings. ref SDS 0 QQ7O
490664 -             ..
490665 -            No intestinal metaplasia (no Barrett's Esophagus)
490667 -             ..
490668 -        e.  Esophagus at 30 cm (biopsy)
490669 -
490670 -            Reflux esophagitis
490671 -
490672 -               [...below see questions on test findings. ref SDS 0 QQ7O
490674 -             ..
490675 -            No intestinal metaplasia (no Barrett's Esophagus)
490676 -
490678 -         ..
490679 -        Comments
490680 -
490681 -        1.  Doctor Patricia Dalton has reviewed this case and concurs.
490683 -             ..
490684 -        2.  This case was processed and examined at the Department of
490685 -            Veterans Affairs, Sacramento Medical Center, 10515 Hospital
490686 -            Way, Mather, CA  95655-1200
490687 -
490689 -  ..
490690 - Questions Arising from EGD Test
490691 -
490692 -
490693 -    1.  It appears that spot biopies found reflux esophagatis.
490694 -        ref SDS 0 MX5K  Did the endoscopy test today on 100305,
490695 -        identify any other problems, e.g., "acid burn" cited by the
490696 -        doctor after the test on 100305 1000. ref SDS 48 PR6P
490698 -         ..
490699 -    2.  How severe is the condition in relation to causing serious
490700 -        illness, complications, cancer?  Is reflux esophagitis expected
490701 -        from suffering achalasia for 5 years; or, do most people have
490702 -        reflux esophagitis at age 65?  Since there is minimal digestion
490703 -        of food into the stomach with achalasia, is reflux esophagitis
490704 -        unexpected, except from food that stays in the esophagus?
490706 -         ..
490707 -    3.  If untreated and left alone, how long before complications can
490708 -        be expected to occur in this case?  Now that swallowing has
490709 -        increased following Heller Myotomy surgery on 091216, can this
490710 -        condition tested in March 2010, be expected to get worse or
490711 -        better without treatment?
490712 -
490713 -            [On 100331 1448 VA letter seems to expand understandings
490714 -            from meeting on 100305, ref SDS 48 PR6P, and presented
490715 -            in feedback letter to the VA on 100317 1213. ref SDS 50
490716 -            PT6W, to relate test findings of general reflux
490717 -            esophagitis, rather than or in addition to mere "acid
490718 -            burn" on the flap for the esophageal sphincter valve.
490719 -            ref SDS 51 YW5S
490721 -             ..
490722 -            [On 100331 1448 Doctor Lee's letter does not present
490723 -            analysis on severity of reflux esophagitis, ref SDS 51
490724 -            XK5G, presented in questions today. ref SDS 0 QQ8M
490725 -
490726 -
490727 -
490728 -
490729 -
490730 -
490731 -
490732 -
490733 -
4908 -