CONTACTS
SUBJECTS
VA Medical Records 091018-100115 CD Rceived Transmittal Heart Surge
1903 -
1903 - ..
1904 - Summary/Objective
1905 -
190501 - Follow up ref SDS 23 0000. ref SDS 22 0000.
190502 -
190503 -
190505 - ..
1906 -
1907 -
1908 - Background
1909 -
190901 - On 100830 Received call from VA Medical Center in San Francisco
190902 - confirming they are preparing a CD, ref SDS 21 6N5J, of medical records
190903 - for period 091018 - 1000101, and ordered at Patient Records at VA
190904 - Clinic in Martinez on 100825 0947. ref SDS 19 QE5F
190906 - ..
190907 - On 100914 1149 called and talked to Jeff, who said Vera was still
190908 - working on the order, ref SDS 22 6N5J; also called Vera and left a
190909 - message asking for expected schedule to complete request for medical
190910 - records on CD. ref SDS 22 OF7M
190912 - ..
190913 - On 100927 1124 called VA and was told the order is completed but there
190914 - is no record on putting the records on a CD nor that the records have
190915 - been mailed to the customer. ref SDS 23 EX7H
190917 - ..
190918 - On 100928 0706 Vera called and advised that she completed the CD on
190919 - the medical records last Thursday. ref SDS 0 EX7H Later in the
190920 - morning, received the CD from Vera. ref SDS 0 NA4Y
190921 -
190922 -
190924 - ..
1910 -
1911 -
1912 - Progress
1913 -
191301 - Telephone for Vera.................. 415 221 4810 ext 5742
191303 - ..
191304 - Telephone for patient records....... 415 750 6607
191306 - ..
191307 - Vera called this morning. She advised that last Thursday, she mailed
191308 - the CD with medical records for the request on 100825 0947.
191309 - ref SDS 19 QE5F
191311 - ..
191312 - This resolves call last week on 100914 1149, ref SDS 22 6N5J, and
191313 - follow up call yesterday on 100927 1124. ref SDS 23 LR7G
191314 -
191316 - ..
1914 -
1915 -
1916 - 1015
1917 -
191701 - Received letter from Vera at VA Medical Center in San Francisco, and
191702 - transmitting medical records for heart and esophageal surgeries.
191703 - ref DRT 1 0001
191704 -
191705 - [On 101207 1152 VA reports patient medical records will
191706 - soon be available on the Internet, similar to online
191707 - banking. ref SDS 24 5V31
191709 - ..
191710 - Received in mail CD with electronic medical records (EMR) requested on
191711 - 100825 0947. ref SDS 19 QE5F
191713 - ..
191714 - VA's advanced health care implementing EMR significantly enhances
191715 - doctor patient partnership that improves quality of medical care,
191716 - cited in research last year on 091113 1017. ref SDS 11 Z65L
191717 -
191718 -
191719 - Medical Records CD Heart Throat Surgery VA
191720 - VA Medical Center SF
191721 - Sudduth Vera C
191725 - ..
191726 - Lab reports are included, and show WBC consistently elevated above top
191727 - range of 10.8. ref DRT 1 UPRS
191729 - ..
191730 - Lab at VA Martinez on 091117, and reviewed during meeting at VA
191731 - Medical Center in San Francisco on 091119, is not mentioned in that
191732 - record. ref DRT 1 TV4H
191733 -
191735 - ..
191736 - Cholesterol was tested only in the lab on 091214. ref DRT 1 O35N
191737 -
191738 - LAB RESULTS UNITS RANGE
191739 - CHOL 241 H mg/dL 100 - 240
191740 - TRGL 136 mg/dL 10 - 190
191741 - HDL 44 mg/dL 35 - 131
191742 - LDL 170 H mg/dL 36 - 128
191744 - ..
191745 - [On 111117 1415 history of all lipids since 2005, shows erratic
191746 - test results, ref SDS 26 R85N; main focus on lower LDL shows
191747 - large swings below and above target health LDL level while
191748 - taking simvastatin 40 mg, and changing to rosuvastatin 20 mg.
191749 - ref SDS 26 5X6U; further shown in graph. ref SDS 26 7M42
191750 -
191752 - ..
191753 - There is work to add links between the Index and the data.
191754 -
191755 -
191756 -
191757 -
191759 - ..
191760 - Blood Clot Thrombus Embolism Not Reported
191761 - Angiogram Cardiac Catheterization Procedure Note
191762 -
191763 - Doctor Shunk reports findings that justify CABG...
191764 -
191765 - 1. LOCAL TITLE: CARDIAC CATHETERIZATION REPORT....... ref DRT 1 3495
191766 - STANDARD TITLE: CARDIOLOGY REPORT
191767 - DATE OF NOTE: OCT 21, 2009@10:57 ENTRY DATE: OCT 21, 2009@10:57:56
191768 - AUTHOR: BEATTY,ALEXIS L EXP COSIGNER: SHUNK,KENDRICK A
191769 - URGENCY: STATUS: COMPLETED
191771 - ..
191772 - CARDIOVASCULAR DIAGNOSTIC AND THERAPEUTIC PROCEDURE REPORT,
191773 - ref DRT 1 IN5J
191775 - ..
191776 - Procedures: Left Heart Catheterization, LV Angiography,
191777 - Coronary Angiography, Femoral Angiography. ref DRT 1 OU8K
191779 - ..
191780 - LV-ANGIOGRAPHY
191781 - EF = 55% Abnormal - Segmental wall motion......... ref DRT 1 WX3M
191783 - ..
191784 - 2. CORONARY ANGIOGRAPHY..................... ref DRT 1 H24L
191785 - Native Vessels
191786 - Summary: 3 vessel CAD
191787 - Dominance: Right dominant
191788 -
191789 - [...below cardiac thoracic surgery team performed CABG on a
191790 - 4th blood vessel; record is unclear on findings.
191791 - ref SDS 0 HT9G
191793 - ..
191794 - [On 091106 1000 book crediting VA for best medical quality
191795 - care, ref SDS 10 VT6M, aligns with this record today
191796 - showing comprehensive patient history captured in Progress
191797 - Notes and tests applied across multiple disciplines that
191798 - leverage coordination among VA medical doctors and nurses
191799 - enabled through doctor/patient partnership. ref SDS 0 H24L
191801 - ..
191802 - Stenoses Details
191804 - ..
191805 - Segment Stenosis * Characteristics and Comments
191807 - ..
191808 - Left Main
191809 - Proximal LAD Large caliber vessel. There is a proximal
191810 - origin of D1.
191811 - Mid LAD 95 Serial stenoses of 70% and 95% after the origin
191812 - of D1.
191813 - Distal LAD Extends to the apex of the heart. TIMI 2 flow.
191814 - 1st Diagonal Large caliber vessel. There is a 70% stenosis
191815 - in the proximal vessel.
191816 - 2nd Diagonal Medium caliber vessel.
191817 - Ramus Intermedius 70 Large caliber vessel. There is a 70% stenosis
191818 - at the bifurcation of the vessel.
191819 - Proximal Circumflex Small caliber vessel.
191820 - Mid Circumflex Small caliber vessel.
191821 - 1st Obtuse Marginal Small caliber vessel.
191822 - Proximal RCA 95 Large caliber vessel
191823 - Mid RCA
191824 - Distal RCA
191825 - Right PDA Medium caliber vessel.
191826 - Right PAV Segment Medium caliber vessel.
191827 - Right PL Segment 1 Small caliber vessel.
191828 - Right PL Segment 2 Medium caliber vessel.
191829 -
191830 -
191831 - * Highest % Stenosis Within Segment
191833 - ..
191834 - 3. FEMORAL ANGIOGRAPHY
191835 -
191836 - Sheath is in the common femoral artery at the level of the
191837 - mid-femoral head at the bifurcation. There is no
191838 - angiographically significant disease on the right.
191840 - ..
191841 - Here are findings that identify requirement for heart surgery.
191843 - ..
191844 - Continue Angiogram Cardiac Catheterization Procedure Note...
191845 -
191846 - 4. FINAL DIAGNOSIS
191847 -
191848 - 1. Multivessel coronary artery disease
191849 - 2. TIMI 2 flow in distal LAD and distal RCA
191850 - 3. Intraprocedural hypotension responsive to IV fluids
191852 - ..
191853 - There is nothing expressly stated in over 600 pages of medical chart
191854 - finding "blood clots," "thrombus," nor "embolism." even with severe
191855 - (95%) "stenosis," which presents high risk of blood clots. Aligns
191856 - with patient history performing angiogram test in Cath Lab on 091021
191857 - 0716. ref SDS 5 7L43
191859 - ..
191860 - Continue Angiogram Cardiac Catheterization Procedure Note...
191861 -
191862 - 5. RECOMMENDATIONS
191863 -
191864 - 1. Consult CT surgery for consideration for CABG
191865 - 2. Admit to ICU for further medical management of CAD prior to intervention.
191866 - 3. Initiate heparin drip.
191867 - 4. Recommend TTE to further evaluate LV function.
191869 - ..
191870 - Unclear in the record if "TTE" in Recommendations #4, above,
191871 - ref SDS 0 XW6M, is a misspelling of "TEE" (or vice versa) cited in
191872 - medical chart the next day saying TEE will not be used, reported on
191873 - 091022, ref SDS 0 I25G, and filed in amendment to anesthesia pre-op
191874 - plan filed on 091021 1705, per above. ref SDS 0 WP4F
191875 -
191876 - [...below cardiac thoracic surgery team performed CABG on a
191877 - 4th blood vessel; record is unclear on findings.
191878 - ref SDS 0 HT9G
191879 -
191880 -
191882 - ..
191883 - Advance Directive Guide Patient Choices Ending Life
191884 -
191885 - Advance Directive signed 091023, ref DRT 1 XSTT and ref DRT 1 LM4X
191886 - reported in the record at that time on 091023 0445. ref SDS 7 WO5Y
191888 - ..
191889 - For some reason, the VA reported for EGD procedure there is no Advance
191890 - Directive on file, reported 100305 1000. ref SDS 16 MV6M
191891 -
191892 - [On 110218 0730 Iris, lead nurse in GI Department for VA
191893 - Martinez advised that patient medical records for Advance
191894 - Directive on file in the San Francisco Medical Center is
191895 - not available to the VA Clinic in Martinez. ref SDS 25 EE4L
191896 -
191897 -
191898 -
191899 -
191901 - ..
191902 - Errors Medical Chart ICU Admission Record 091021...
191903 -
191904 -
191905 - 1. LOCAL TITLE: NURSING ADMISSION ASSESSMENT NOTE PART 1
191906 - DEMOGRAPHI................................... ref DRT 1 6R6N
191907 - STANDARD TITLE: NURSING ADMISSION EVALUATION NOTE
191908 - DATE OF NOTE: OCT 21, 2009@21:33 ENTRY DATE: OCT 21, 2009@21:33:40
191909 - AUTHOR: SOUTH,DOUGLAS C EXP COSIGNER:
191910 - URGENCY: STATUS: COMPLETED
191912 - ..
191913 - PATIENT ADMITTED WITH:
191914 - Other: computer lap top.................. ref DRT 1 GS6O
191915 -
191917 - ..
191918 - Nutrition Screen....................... ref DRT 1 QVPX
191920 - ..
191921 - Do you have any problem with swallowing or chewing? No...
191922 - ref DRT 1 QVPX
191924 - ..
191925 - Do you have any problems with Nausea/Vomiting, Diarrhea
191926 - or Constipation? No......... ref DRT 1 KY8K
191928 - ..
191929 - Without wanting to, have you lost > 10 pounds in the last 6
191930 - months? No.......... ref DRT 1 RWSR
191932 - ..
191933 - Does the patient Cough or choke when swallowing foods
191934 - or liquids? No................... ref DRT 1 QQYT
191936 - ..
191937 - Does Food or liquids get stuck in the patients throat when
191938 - drinking or eating? No................ ref DRT 1 RW9F
191940 - ..
191941 - These are all errors; uniformity of answers suggests perfunctory
191942 - assumptions by busy staff. The patient was referred for heart
191943 - examination, based on examination reporting complications of
191944 - swallowing problems with associated chronic vomitting, caused by
191945 - achalasia for past 5 years. Case study on 091021 0716, shows that
191946 - over the previous days, swallowing and vomitting problems were
191947 - reported extensively to 14 doctors asking about patient history.
191948 - ref SDS 5 FB5N
191950 - ..
191951 - Reflects Doctor Brzezinski's report the next day on 091022, that
191952 - nobody told him about achalasia, and that complications could cause
191953 - death during heart surgery performed later that day, without special
191954 - provisions using a heart pump to avoid aspiration. ref SDS 6 JF9K
191955 -
191957 - ..
191958 - Pre-op Meeting Medical Team ICU
191959 -
191960 - Nurse reports met with medical team in ICU the day before surgery on
191961 - 091021 1520. ref DRT 1 RK4M
191962 -
191964 - ..
191965 - Heart Function Appears Normal - Good News
191966 -
191967 - Cardiology Ecocardiogram report on 091021 1958, pre-op most everything
191968 - appears "normal," ref DRT 1 QVVX, for ecocardiogram test performed
191969 - earlier in the day 091021 1158. ref DRT 1 TQ4G
191970 -
191971 - Cardiac Chambers:
191973 - ..
191974 - Left Ventricle: The left ventricular volume is normal. There
191975 - is mild left ventricular hypertrophy. The pattern of
191976 - hypertrophy is concentric. The left ventricular ejection
191977 - fraction is estimated to be 70 to 75%. No segmental wall
191978 - motion abnormalities present. ref DRT 1 K27M
191980 - ..
191981 - Research on the Internet says...
191982 -
191983 - Mayoclinic.com
191984 -
191985 - Left ventricular hypertrophy
191986 -
191987 - http:/ www.mayoclinic.com/health/left-ventricular-hypertrophy/DS00680
191989 - ..
191990 - Left ventricular hypertrophy is enlargement (hypertrophy)
191991 - of the muscle tissue that makes up the wall of your
191992 - heart's main pumping chamber (left ventricle).
191994 - ..
191995 - Symptoms
191997 - ..
191998 - Left ventricular hypertrophy usually develops gradually.
191999 - You may experience no signs or symptoms, especially during
192000 - the early stages of the condition. As left ventricular
192001 - hypertrophy progresses and complications develop, you may
192002 - experience these left ventricular hypertrophy symptoms:
192003 -
192004 - 1. Shortness of breath
192005 - 2. Chest pain
192006 - 3. Sensation of rapid, fluttering or pounding
192007 - heartbeats (palpitations)
192008 - 4. Dizziness
192009 - 5. Fainting
192010 - 6. Rapid exhaustion with physical
192011 - activity
192013 - ..
192014 - All of these symptoms except fainting and rapid exhaustion, have
192015 - occurred to some degree.
192017 - ..
192018 - On 091024 0600 a-fibulation occurred 2 days after heart surgery, shown
192019 - in the medical chart entered by KC, ref DRT 1 HQ6O, which is part of
192020 - the recovery process. ref SDS 8 HR7G This actually occurred twice.
192021 - The first event was in the morning, and lasted only 20 minutes or so.
192022 - However, the second occurred the next morning in the early AM and took
192023 - several hours to resolve. ref SDS 8 G44N
192025 - ..
192026 - So far, cannot find in the medical chart the report of the 2nd and
192027 - longer afib event. Why report a 20 minute problem, and not report a
192028 - seemingly more severe problem that took hours to solve?
192030 - ..
192031 - On 091026 Jan reported another occurrence of a-fib, ref DRT 1 99EG,
192032 - which did not last long.
192034 - ..
192035 - Have reported several times since surgery on 091022, feeling
192036 - palpitations that cause the body to rock when laying down. These
192037 - have generally been mild and isolated events.
192039 - ..
192040 - Should it be expected that mild left ventricular hypertrophy will
192041 - improve a year after successful heart bypass surgery?
192043 - ..
192044 - Diastolic Function: There is Doppler evidence of impaired LV
192045 - relaxation which may be normal for the patient's age. Mitral A wave
192046 - dominance with systolic predominant pulmonary venous flow suggests
192047 - normal LV filling pressures. ref DRT 1 N44M
192049 - ..
192050 - Pulmonary Artery Pressure:
192052 - ..
192053 - Aorta: The aortic root size is upper limits of normal to borderline
192054 - dilated at the Sinuses of Valsalva. ref DRT 1 ME5I
192055 -
192057 - ..
192058 - Cardiology Contact Note after angiogram........ ref DRT 1 SU4N
192059 -
192061 - ..
192062 - LOCAL TITLE: CARDIOTHORACIC PREOPERATIVE
192063 - CHECKLIST (SURG)................................. ref DRT 1 L44F
192064 - STANDARD TITLE: SURGERY PRE OPERATIVE E & M NOTE
192065 - DATE OF NOTE: OCT 21, 2009@18:45 ENTRY DATE: OCT 21, 2009@18:45:34
192066 - AUTHOR: CAMBRONERO,NEIL EXP COSIGNER:
192068 - ..
192069 - For some reason there is no work plan to accomodate complications from
192070 - achalasia, nor any mention of risks from aspiration, discussed at
192071 - length earlier in the day with the CT surgery team on 091021 0716 at
192072 - 1429. ref SDS 5 NX6M Lack of notice in preop checklist aligns with
192073 - Doctor Brzezinski's report the next day that nobody told him to be
192074 - prepared for solving Achalsia problem, shown on day of surgery 091022
192075 - 0700. ref SDS 6 JF9K
192076 -
192077 - [...below, Operation Report, cites patient achalasia
192078 - required changes to standard CABG procedures, ref SDS 0
192079 - 633I, and that cardiopulmonary bypass was applied.
192080 - ref SDS 0 H26O
192081 -
192082 -
192084 - ..
192085 - Achalasia Risk Death Aspiration Not Presented Anesthesia Work Plan
192086 - Anesthesia Pre-op Eval No Planning Avoid Aspiration due to Achalasia
192087 -
192088 - LOCAL TITLE: ANESTHESIA PRE-ANESTHETIC EVAL........... ref DRT 1 WP4F
192089 - STANDARD TITLE: ANESTHESIOLOGY PRE OPERATIVE E & M NOTE
192090 - DATE OF NOTE: OCT 21, 2009@17:05 ENTRY DATE: OCT 21, 2009@17:05:29
192091 - AUTHOR: GEBAUER,SARAH LANGL EXP COSIGNER:
192092 - URGENCY: STATUS: COMPLETED
192094 - ..
192095 - HPI: Patient c/o 5/10 chest pain 6 weeks ago during hiking. He denies
192096 - any SOB, orthopnea, or PND. In September, during a pre-op workup for
192097 - his achalasia, he had a treadmill stress test which was positive with
192098 - a 2mm ST depression in V5 after 6:59 of exercise. He was then
192099 - referred to the VA for cardiac catheterization. His cardiac
192100 - catheterization from 10/21/09 showed multi-vessel CAD with tight
192101 - lesions of LAD, LADD, RCA, and Ramus Intermedius with TIMI 2 flow in
192102 - the distal LAD and RCA. After the catheterization CT surgery was
192103 - consulted and heparin gtt was initiated. He is currently in the ICU
192104 - awaiting urgent CABG on 10/22 due to concerning anatomy. ref DRT 1
192105 - PZ3L
192107 - ..
192108 - ASSESSMENT: ASA: IV NPO after 2400 except meds, ref DRT 1 SW6N
192110 - ..
192111 - PLAN: Plan for GETA with cordis, PA catheter, and 2 PIVs.
192113 - ..
192114 - Anesthesia options, benefits and risks including: H/A, N/V, S/T,
192115 - Dental damage, nerve damage, bleeding, stroke, pneumonia, MI and death
192116 - were discussed. Patient verbalized understanding and wishes to
192117 - proceed with operation. ref DRT 1 K54K
192118 -
192119 - [...below anesthesia options does not expressly plan to
192120 - prevent aspiration due to achalasia. ref SDS 0 YN69
192122 - ..
192123 - This record indicates VA anesthesia team knew about achalasia, but did
192124 - not formaulate plans and procedures to prevent aspiration, until
192125 - meeting with Doctor Brzezinski, Chief of Anesthesia. who was asked for
192126 - VA's work plan, reported on 091022 0700, ref SDS 6 JF9K At that time,
192127 - the doctor indicated he was not notified about achalasia, and was not
192128 - familiar with symptoms and impact on heart surgery. He performed
192129 - research on VA computer with assistance of SDS record, ref SDS 6 JF9L,
192130 - and then ordered cardiopulmonary bypass pump to avoid risks of
192131 - aspiration. ref SDS 6 GX4J
192133 - ..
192134 - [...below, Operation Report, cites patient achalasia
192135 - required changes to standard CABG procedures, ref SDS 0
192136 - 633I, and that cardiopulmonary bypass was applied.
192137 - ref SDS 0 H26O
192138 -
192140 - ..
192141 - Achalasia Risk Death Aspiration Added Work Plan Collaboration Patient
192142 - Anesthesia Work Plan Amended for Achalasia Collaboration with Patient
192143 -
192144 - The next day on 091022 0926, Doctor Brzezinski filed amendments
192145 - changing Anesthesia work plan to prevent complications from achalasia,
192146 - ref DRT 1 E54N, after reviewing patient history during pre-op
192147 - preparations in the OR, reported on 091022 0700. ref SDS 6 JF9K
192149 - ..
192150 - Amendment states in part...
192151 -
192152 - we will not use the TEE.......... ref DRT 1 H15I
192154 - ..
192155 - Doctor Brzezinski's ammended work plan aligns with discussions on
192156 - risks of death due to aspiration during heart surgery. ref SDS 6 GX4J
192157 -
192158 - [...below Neil's operation report says surgery procedure
192159 - was modified by eliminating transesophageal probe.
192160 - ref SDS 0 BY4K
192161 -
192162 -
192164 - ..
192165 - Meeting with Medical Team Day Before Surgery
192166 -
192167 - LOCAL TITLE: CARDIOTHORACIC ATTENDING NOTE (SURG)
192168 - STANDARD TITLE: SURGERY ATTENDING NOTE
192169 - DATE OF NOTE: OCT 21, 2009@14:35 ENTRY DATE: OCT 21, 2009@14:35:11
192170 - AUTHOR: TSENG,ELAINE EXP COSIGNER................ ref DRT 1 SY8G
192171 - URGENCY: STATUS: COMPLETED
192173 - ..
192174 - Attending physician's note does not mention awareness of achalasia and
192175 - complications of aspiration, which were presented during meeting with
192176 - medical team, reported on 091021. ref SDS 5 FB5N This aligns with
192177 - Sarah's pre-op anesthesia planning note, per above. ref SDS 0 6G4F
192178 -
192180 - ..
192181 - Consent CABG Heart Surgery Signed
192182 - Informed Consent Heart Bypass CABG Surgery
192183 -
192184 - The formal consent document signed on 091021 1419, is included in the
192185 - medical chart and was signed before meeting with the medical team. It
192186 - was presented by Joe, one of the doctors, ref DRT 1 ZG7I, and as
192187 - reported in the record on 091021 0716 at 1415. ref SDS 5 ST9K
192189 - ..
192190 - Purpose of surgery is to repair "poor blood supply to the heart."
192191 - ref DRT 1 GV9H
192193 - ..
192194 - This has a good explanation of scope of work for CABG surgery.
192195 -
192196 -
192198 - ..
192199 - Heart Bypass CABG Surgery Explanation Informed Consent
192200 - CABG Surgery Heart Bypass Explanation Informed Consent
192201 - Explanation CABG Surgery Heart Bypass Informed Consent
192202 -
192203 - 7. Treatment/procedure: CORONARY ARTERY BYPASS GRAFT (CABG) Your
192204 - breastbone is cut down the middle. Your ribs are pulled back. This
192205 - is to give the doctor access to your heart. A graft is placed around
192206 - narrowed or blocked parts of one or more coronary arteries. This
192207 - allows blood to flow freely past the blocked parts. The graft is a
192208 - blood vessel from another part of your body. It may be taken from the
192209 - leg, chest, or arm. The operation is done with heart-lung bypass
192210 - (cooling the body and temporarily stopping the heart and lungs).
192211 - ref DRT 1 TQ6N
192212 -
192213 -
192214 -
192216 - ..
192217 - Work Plan Missing Surgery CABG
192218 - Surgery Work Plan Not Evident in Medical Chart
192219 -
192220 - During a meeting in ICU with the CT surgery team, asked to see the
192221 - work plan for CABG implementing findings from the angiogram test
192222 - earlier in the morning. At that time, Doctor Tseng seemed to indicate
192223 - planning for surgery would be reported in the medical chart, as shown
192224 - in the record on 091021 0716, ref SDS 5 C65O
192226 - ..
192227 - Cannot find a work plan in the medical chart for the actual surgery.
192229 - ..
192230 - There is a very detailed work plan for anesthesia preapred the day
192231 - before surgery, per above, ref SDS 0 WP4F, and that plan was amended
192232 - the next day prior to surgery in time to be effective avoiding risks
192233 - of fatality from aspiration due to achalasia. ref SDS 0 I25G
192235 - ..
192236 - Nothing seems to be presented on scope and details of surgery based on
192237 - findings from angiogram test that found 3 severe blood flow blockages,
192238 - reported on 091021 0716. ref SDS 5 7L43
192239 -
192240 -
192242 - ..
192243 - Surgery Heart Bypass Operation Report
192244 - Operation Report Heart Bypass CABG x4
192245 - Good Quality Veins Found for Bypass Grafts Portends Healthy Recovery
192246 -
192247 - LOCAL TITLE: OPERATION REPORT............... ref DRT 1 S89M
192248 - STANDARD TITLE: OPERATIVE REPORT
192249 - DICT DATE: OCT 22, 2009 ENTRY DATE: OCT 22, 2009@17:51:19
192250 - SURGEON: CAMBRONERO,NEIL ATTENDING: TSENG,ELAINE
192251 - URGENCY: STATUS: COMPLETED
192252 - SUBJECT: Case #: 1070425
192254 - ..
192255 - This is the operation reported on 091022 0700. ref SDS 6 LO3G
192257 - ..
192258 - INDICATIONS FOR SURGERY: This is a 64-year-old man who had recent
192259 - onset of angina and underwent cardiac catheterization, and he was
192260 - found to have an extremely tight LAD lesion with TIMI II flow. He
192261 - also had multiple other lesions and severe three-vessel disease and is
192262 - referred for urgent coronary artery bypass grafting. He was in the
192263 - ICU on a Heparin drip. He has normal ventricular function. ref DRT 1
192264 - 1G3O
192266 - ..
192267 - [On 091106 1000 book crediting VA for best medical quality
192268 - care, ref SDS 10 VT6M, aligns with this record today
192269 - showing comprehensive patient history captured in Progress
192270 - Notes and tests applied across multiple disciplines that
192271 - leverage coordination among VA medical doctors and nurses
192272 - enabled through doctor/patient partnership. ref SDS 0 C58I
192274 - ..
192275 - Cardiothoracic Surgery Team...................... ref DRT 1 UPQP
192277 - ..
192278 - Surgeon: CAMBRONERO,NEIL First Assist: KANKA,KRISTIN C
192279 - Attend Surg: TSENG,ELAINE Second Assist: PRICE,PAULA
192280 - Anesthetist: GEBAUER,SARAH LANGLEY Assistant Anesth: N/A
192282 - ..
192283 - Looks like KC is Doctor Kristin C Kanaka, who did outstanding work
192284 - coordinating the feeding tube issue, reported on 091030 0810 at 1522.
192285 - ref SDS 9 PRTX
192286 -
192288 - ..
192289 - Achalasia Condition Modified Surgery Procedure
192290 -
192291 - DESCRIPTION OF THE OPERATION: The patient was brought to the
192292 - Operating Room and placed in the supine position. Central venous and
192293 - arterial monitoring lines, a Foley catheter and a Swan-Ganz catheter
192294 - were inserted. Due to the patient's achalasia, a transesophageal echo
192295 - probe was not inserted. The chest, groins and legs were prepped and
192296 - draped in the usual sterile fashion. ref DRT 1 BY4K
192298 - ..
192299 - Unclear in the record if eliminating transesophageal echo probe
192300 - reflects Doctor Brzezinski's amended work plan not to perform TEE,
192301 - noted above. ref SDS 0 I25G
192302 -
192304 - ..
192305 - Leg Vein Harvested Simultaneous Median Sternotomy
192306 -
192307 - A median sternotomy was performed. The left internal mammary artery
192308 - was taken down as a pedicled graft and injected with dilute Papaverine
192309 - solution. Branches were clipped on the artery side and
192310 - electrocoagulated on the chest wall side. Saphenous vein was
192311 - harvested simultaneously from the leg. Heparin 300 units/kg was
192312 - administered. ref DRT 1 AI5H
192314 - ..
192315 - CABG surgery is explained in Wikipedia...
192316 -
192317 - https://en.wikipedia.org/wiki/Coronary_artery_bypass_surgery
192319 - ..
192320 - Diagram of typical CABG +4...
192321 -
192322 - https://upload.wikimedia.org/wikipedia/commons/4/48/Blausen_0154_CABG_Quadruple.png
192323 -
192324 -
192326 - ..
192327 - Needle Missing After Surgery
192328 -
192329 - After surgery, inventory discovered possible missing needle. Chest
192330 - xray was performed, and there was no evidence in the xray report on
192331 - finding the missing needle. ref DRT 1 68F4
192332 -
192333 - Radiology Report says in part...
192335 - ..
192336 - Impression:
192337 -
192338 - 1. Portable supine chest radiograph in the operating room
192339 - demonstrates no findings suspicious for a metallic needle.
192340 -
192341 - [On 160104 0855 applied this finding to support using
192342 - CCTA to report no findings suspicious for
192343 - atherosclerosis plaque or blockages of any kind or
192344 - amount. ref SDS 31 SL9J
192346 - ..
192347 - 2. In addition there is an endotracheal tube the tip of which
192348 - overlies the midtrachea and a right jugular pulmonary
192349 - artery catheter the tip of which overlies the right
192350 - ventricular outflow region. Two left chest tubes.
192351 - Epicardial pacer wires. Bilateral surgical clips. What
192352 - appears to be a 1.5 by a 12 cm well-defined hazy density
192353 - overlying the right lung base, likely a drain or a lap
192354 - tape.
192356 - ..
192357 - 3. New somewhat triangular density overlies the area of the
192358 - left heart, possibly something extrinsic to the patient
192359 - versus partial left lower lobe atelectasis.
192361 - ..
192362 - Primary Diagnostic Code:
192363 - Primary Interpreting Staff:
192364 - MARCIA J. MCCOWIN, M.D., Staff Radiologist UC# 25632 (Verifier)
192365 - /MJM
192366 - CXR AP PORT
192367 - Exm Date: OCT 22, 2009@17:58
192368 -
192369 -
192371 - ..
192372 - 4 Heart Bypass Grafts Performed During CABG +4 Surgery
192373 - Blood Flow 4th Blockage Stenosis Discovered Repaired During Surgery
192374 -
192375 - Medical chart reports the surgery on 091022, ref SDS 6 PQWU, performed
192376 - 4x CABG, one more than reported in findings from angiogram test the
192377 - day before on 091021, shown above. ref SDS 0 H24L
192378 -
192379 - 1. PDA grafted....- saphaneous............90 cc/min.. ref DRT 1 TL3N
192380 - 2. LADD1 grafted...- saphaneous..........100 cc/min.. ref DRT 1 TYPY
192381 - 3. Ramus coronary artery..- saphaneous...100 cc/min.. ref DRT 1 3N5N
192382 - 4. LAD grafted..- LIMA subclavian.........?? cc/min.. ref DRT 1 TYRW
192384 - ..
192385 - Appears the left internal mammary artery (LIMA) from the subclavian
192386 - was grafted to the left anterior descending (LAD) coronary artery, all
192387 - with good blood flow, discussed below. ref SDS 0 YI7K
192388 -
192389 - [On 151028 1000 Doctor Simpson comments in Progress Notes
192390 - that CCTA results on 151019 "... could be read as showing
192391 - some early changes in the [...saphenous vein grafts...]
192392 - SVGs. This is about what I had predicted." ref SDS 30 5Y6L
192394 - ..
192395 - It is difficult to correlate descriptions of the 4 grafts performed in
192396 - surgery, with 3 stenosis summarized in the angiogram test (cardiac
192397 - cathertization) the day before, per above. ref SDS 0 H24L
192399 - ..
192400 - How was the 4th bypass graft discovered, what level of blockage or
192401 - other medical defect was determined that justified bypass surgery at
192402 - this location?
192403 -
192404 -
192405 -
192407 - ..
192408 - Cardiology Circulatory Blood Flow Good Quality 4 Bypass Grafts
192409 -
192410 - FINDINGS AT THE OPERATION: The aorta was soft. The left internal
192411 - mammary artery was of good quality and was 1.4 mm in diameter and had
192412 - good flow. The saphenous vein was of good quality and was 4 mm in
192413 - diameter. The left anterior descending coronary artery was a good
192414 - target and was 1.7 mm in diameter. The left anterior descending
192415 - diagonal #1 coronary artery was a good target and was 1.5 mm in
192416 - diameter. The ramus coronary artery was 1.5 mm in diameter and a good
192417 - target. The posterior descending coronary artery was a good target
192418 - and was 1.7 mm in diameter. ref DRT 1 YI7K
192420 - ..
192421 - A median sternotomy was performed. The left internal mammary artery
192422 - was taken down as a pedicled graft and injected with dilute Papaverine
192423 - solution. Branches were clipped on the artery side and
192424 - electrocoagulated on the chest wall side. Saphenous vein was
192425 - harvested simultaneously from the leg. Heparin 300 units/kg was
192426 - administered. ref DRT 1 AI5H
192428 - ..
192429 - Saphenous vein was used for 3 of 4 bypass grafts, per above.
192430 - ref SDS 0 HT9G
192432 - ..
192433 - Neil's report finding "good quality" blood vessels that are "good
192434 - targets" for heart bypass grafts, gives confidence there is not
192435 - general widespread circulatory disease, and that replacement grafts
192436 - can hold up for a long time with good post-op diet and exercise.
192437 - Hopefully, Neil was not padding the record to justify what was done.
192438 -
192439 -
192440 -
192442 - ..
192443 - Achalasia Condition Modified Standard Procedure CABG
192444 - Cardio Pulminary Bypass Accomodate Achalasia Avoid Asperation
192445 -
192446 - Follow up ref SDS 6 JF9K.
192447 -
192448 - DESCRIPTION OF THE OPERATION: The patient was brought to the
192449 - Operating Room and placed in the supine position. Central venous and
192450 - arterial monitoring lines, a Foley catheter and a Swan-Ganz catheter
192451 - were inserted. Due to the patient's achalasia, a transesophageal echo
192452 - probe was not inserted. The chest, groins and legs were prepped and
192453 - draped in the usual sterile fashion. ref DRT 1 BY4K
192455 - ..
192456 - The patient was placed on cardiopulmonary bypass. A vent was inserted
192457 - into the pulmonary artery. The aorta was cross-clamped. A liter of
192458 - cold potassium blood cardioplegic solution was instilled into the
192459 - aortic root. The heart became flaccid after 400 cc. After completion
192460 - of antegrade cardioplegia, 500 cc of cold blood potassium cardioplegic
192461 - solution was instilled retrograde through the coronary sinus. The
192462 - patient was allowed to drift in temperature. ref DRT 1 H26O
192463 -
192464 - [...above Preoperative Checklist does not mention problem
192465 - of achalasia, nor plans for cardiopulmonary bypass.
192466 - ref SDS 0 L44F
192468 - ..
192469 - "Cardiopulmonary bypass" was ordered during pre-op planning when
192470 - Doctor Brzezinski discovered patient suffers achalasia with risk of
192471 - aspiration, discussed during preparation for anesthesia, reported on
192472 - 091022 0700. ref SDS 6 GX4J
192473 -
192474 -
192475 -
192477 - ..
192478 - Thrombus Blood Clot Discovered Cordis Catheter
192479 -
192480 -
192481 - 1. LOCAL TITLE: VASCULAR SURGERY PROGRESS NOTE......... ref DRT 1 92F7
192482 - STANDARD TITLE: VASCULAR SURGERY E & M NOTE
192483 - DATE OF NOTE: OCT 30, 2009@17:42 ENTRY DATE: OCT 30, 2009@17:42:29
192484 - AUTHOR: BAGGA,HERMAN S EXP COSIGNER:
192485 - URGENCY: STATUS: COMPLETED
192487 - ..
192488 - 2. The Attending Physician of record for this patient care
192489 - encounter is Dr Owens. ref DRT 1 1J3I
192491 - ..
192492 - 3. ID: 64M POD#9 s/p CABG with incidental finding of RIJ filling
192493 - defect on CT chest from yesterday. S/p recent R IJ line
192494 - removal. ref DRT 1 3V5F
192496 - ..
192497 - 4. E: Ultrasound results reviewed today, which show evidence of
192498 - thrombus of right IJ vein. ref DRT 1 GK6I
192500 - ..
192501 - 5. AP: Reccommend 6 weeks of therapeutic anticoagulation with
192502 - lovenox or coumadin followed by repeat ultrasound after this
192503 - course to assess for resolution. If resolved, may d/c
192504 - anticoagulation. If not resolved, please continue patient on
192505 - anticoagulation and contact us to schedule an outpatient clinic
192506 - visit. ref DRT 1 BB6K
192508 - ..
192509 - 6. Vascular Surgery................... ref DRT 1 FL7I
192510 -
192516 -
192517 -
192518 -
192520 - ..
192521 - Fear Anxiety Prevention - Notice Education
192522 -
192523 - LOCAL TITLE: NURSING ICU PICIS NOTE
192524 - STANDARD TITLE: CRITICAL CARE UNIT NOTE
192525 - DATE OF NOTE: OCT 22, 2009@07:20:26 ENTRY DATE: OCT 22, 2009@07:20:26
192526 - AUTHOR: DUNN,BENNIE T JR EXP COSIGNER:
192527 - URGENCY: STATUS: COMPLETED............. ref DRT 1 9933
192529 - ..
192530 - 09 FEAR / ANXIETY. Deal with distorted perception; provide
192531 - info. to reduce distortion. Avoid surprises; tell patient
192532 - what to expect. Include patient in planning care.
192533 - Maintain calm; safe environment; decrease stimuli;
192534 - reassure patient. Pt identifies coping mechanisms
192535 - successful in decreasing fear/anxiety. Teach relaxation
192536 - techniques. \involve family or SO in patient's care.
192537 - Consider anxiolytics (10/21 8:00 PM)....... ref DRT 1 9G5N
192539 - ..
192540 - This record conflicts with the report of significant anxiety and fear
192541 - on waking from surgery and feeling extreme sense of breathing blocked,
192542 - which portended death, and caused by breathing tube inserted into the
192543 - throat to prevent choking from achalasia during heart surgery,
192544 - reported morning after surgery on 091023 0445. ref SDS 7 01F9
192546 - ..
192547 - Conflict likely reflects that achalasia swallowing and breathing
192548 - problem was overlooked, until Doctor Brzenski was reminded again the
192549 - next morning on 091022 0700, ref SDS 6 JF9K, and at that time a plan
192550 - was developed which required leaving the throat obstruction in place
192551 - until the day after surgery, which totally surprised and frightened
192552 - the patient, reported on 091023 0445. ref SDS 7 01F9
192553 -
192555 - ..
192556 - Restraints Applied Prevent Patient Remove Required Medical Tubes
192557 -
192558 - Fear and anxiety experienced the next morning waking up from surgery
192559 - the day before was caused by encountering restraints that prevented
192560 - removing obstructions to breathing. The medical chart explains why
192561 - restraints were applied...
192563 - ..
192564 - 1. LOCAL TITLE: NURSING RESTRAINT NOTE - INITIAL
192565 - STANDARD TITLE: NURSING SECLUSION RESTRAINT NOTE
192566 - DATE OF NOTE: OCT 23, 2009@03:08 ENTRY DATE: OCT 23, 2009@03:08:27
192567 - AUTHOR: PAWLIKOWSKI,JANINE EXP COSIGNER:
192568 - URGENCY: STATUS: COMPLETED
192570 - ..
192571 - All items that apply will be marked with an X.
192572 - The following alternatives to restraint use were tried and were
192573 - unsuccessful:
192574 -
192575 - 1) Ensuring patient's comfort:
192576 - _X__ Provide pain medications if needed
192577 - _X__ Make sure patient is clean and dry
192578 - ___ Anticipate basic needs, such as toileting
192579 - ___ Make sure patient is not hungry or thirsty
192580 - _X__ Minimize nighttime interruptions
192581 - _X__ Promote normal sleep patterns
192582 - ___ Consider medications to relieve anxiety and agitation
192583 - 2) Providing companionship and supervision:
192584 - ___ Ask family, friends, or volunteers to stay with the patient
192585 - ___ Determine when the patient needs one to one attention (typically at
192586 - night) and intervene accordingly
192587 - ___ Contact the patient's spiritual counselor or medical center Chaplain
192588 - 3) Modifying the environment:
192589 - ___ Position the bedside commode and other necessities where the patient
192590 - can use them easily
192591 - ___ Arrange for patient to be near the nurses' station (unless the
192592 - stimulation triggers or worsens agitation)
192593 - PATIENT NAME AND ADDRESS (Mechanical imprinting, if available)
192594 - WELCH, RODNEY
192595 - 1158 ST MATTHEW PLACE
192596 - #103
192597 - CONCORD, CALIFORNIA 94518
192598 - 561720144
192599 - VISTA Electronic Medical Documentation
192600 - Printed at SAN FRANCISCO VAMC
192601 - Page 508
192602 -
192603 -
192604 - Progress Notes Printed On Sep 23, 2010
192605 -
192606 - ___ Keep the call button accessible
192607 - _X__ Reduce environmental noise
192608 -
192609 -
192610 - 4) Providing psychosocial interventions:
192611 - _X__ Provide reality orientation (if it provides comfort)
192612 - ___ Involve the patient in conversation
192613 - _X__ Explain procedures to reduce fear & convey a sense of calm
192614 - _X__ Use relaxation techniques (touch, massage)
192615 - ___ Use active listening to elicit the patient s feelings
192616 -
192617 -
192618 - 5) Offering diversionary and physical activities:
192619 - ___ Use TV, radio, or music for diversion
192620 - ___ Supply books or magazines
192621 - ___ Provide repetitive "chores" (towel folding, paper shredding)
192622 - ___ Provide exercise and ambulation whenever possible
192623 -
192624 -
192625 - 6) Changing or eliminating bothersome treatments:
192626 - ___ Evaluate medication
192627 - ___ Initiate oral (instead of IV or NG) feedings
192628 - _X__ Remove catheters and drains as soon as possible
192629 -
192630 -
192631 - *************************************************
192632 - Time patient placed in restraints:10/21/2009 @ 1930
192633 -
192635 - ..
192636 - Name of provider notified: Dr. Ahn
192637 - Time provider notified: 2000
192638 - *************************************************
192639 -
192641 - ..
192642 - Restraining device used because:
192643 - _X_ Trying to remove tube / line / monitoring equipment
192644 - ___ Trying to get out of bed and could be seriously injured if were to
192645 -
192646 -
192647 - fall
192648 -
192650 - ..
192651 - Explanation of above given to patient. Patient response:
192652 - _X__ Patient appears not to be able to understand explanation given
192653 - ___ Other:
192654 -
192656 - ..
192657 - Type of restraining device(s):
192658 -
192659 -
192660 - ___ Tabletop chair
192661 - ___ Belt
192662 - ___ Vest
192663 - ___ Jacket
192664 - ___ Mitten(s)
192665 - _X__ Soft Limb ___1__X__2____3. Location(s): bilateral wrist
192666 - ___ 4 point
192667 -
192669 - ..
192670 - PATIENT NAME AND ADDRESS (Mechanical imprinting, if available)
192672 - ..
192673 - VISTA Electronic Medical Documentation
192675 - ..
192676 - WELCH, RODNEY
192677 - 1158 ST MATTHEW PLACE
192678 - #103
192679 -
192681 - ..
192682 - Printed at SAN FRANCISCO VAMC
192684 - ..
192685 - CONCORD, CALIFORNIA 94518
192686 - 561720144
192687 -
192689 - ..
192690 - Page 509
192691 -
192692 -
192693 - Progress Notes Printed On Sep 23, 2010
192695 - ..
192696 - Monitoring and Assessment:
192697 -
192698 -
192699 - _X__ Patient is in restraint other than 4-point. The following were
192700 - assessed at least every 2 hours: Need for nutritional intake, hydration,
192701 - elimination, and hygiene; skin integrity, circulation, and security of
192702 - device. Interventions were implemented to address identified needs. At
192703 - least every two hours, each device was released. Each device was removed
192704 - this shift to provide exercise and assess range of motion.
192705 -
192706 -
192707 - ___ Patient in 4-point restraint: The following were assessed at least
192708 - every 15 minutes: Level of agitation, security of device, and general
192709 - status and condition (e.g., observation of respirations, skin color,
192710 - signs of distress). At least every two hours, the need for nutritional
192711 - intake, hydration, elimination, and hygiene were assessed. Interventions
192712 - were implemented to address identified needs. At least every two hours,
192713 - each device was removed to provide exercise and assess skin integrity,
192714 - circulation, and range of motion.
192715 -
192717 - ..
192718 - Results of Assessment:
192719 -
192720 -
192721 - _X__ Skin integrity, circulation and range of motion was normal
192722 - ___ Abnormal findings found on regular assessments: (Describe the
192723 - findings and the interventions required to address the abnormal findings)
192724 -
192726 - ..
192727 - Response to trial release:
192728 -
192729 -
192730 - _X__ Trial release failed. Patient still meets criteria.
192731 - ___ Trial release successful.
192732 - Time restraints discontinued:
192733 -
192735 - ..
192736 - COMMENTS:
192737 -
192738 -
192739 - /es/ JANINE JUHASZ
192740 - PAWLIKOWSKI,JANINE
192741 - Signed: 10/23/2009 03:10
192742 -
192743 -
192745 - ..
192746 - Patient Proactive Case Mangement Doctor Patient Partnership
192747 -
192748 - LOCAL TITLE: NURSING ICU PICIS NOTE............... ref DRT 1 9933
192749 - STANDARD TITLE: CRITICAL CARE UNIT NOTE
192750 - DATE OF NOTE: OCT 22, 2009@07:20:26 ENTRY DATE: OCT 22, 2009@07:20:26
192751 - AUTHOR: DUNN,BENNIE T JR EXP COSIGNER:
192752 - URGENCY: STATUS: COMPLETED
192754 - ..
192755 - 10/21 10:00 PM BTD Activity, Other: - Pt typing with daily events in
192756 - his CPU. ref DRT 1 6G3G
192757 -
192759 - ..
192760 - LOCAL TITLE: NURSING TELEMETRY NOTE............. ref DRT 1 NE6K
192761 - STANDARD TITLE: NURSING CRITICAL CARE UNIT NOTE
192762 - DATE OF NOTE: NOV 03, 2009@04:55 ENTRY DATE: NOV 03, 2009@04:55:20
192763 - AUTHOR: RICE,PATRICIA EXP COSIGNER:
192764 - URGENCY: STATUS: COMPLETED
192766 - ..
192767 - PSYCH/SOCIAL
192769 - ..
192770 - Verbalizes knowledge of Plan of Care: Yes
192771 - Participates in Plan of Care: Yes
192772 - Interacts well with: staff........................ ref DRT 1 3434
192774 - ..
192775 - Other findings: Pt is very detail oriented and documents all his care
192776 - in his laptop computer for his own record-keeping and information. He
192777 - is very thorough historian as to his medical course.
192778 -
192779 -
192780 -
192781 - Sleep Change Positions Avoid Ulcers Patient Training
192784 - Patient Training Sleep Change Positions Avoid Ulcers
192785 - Bed Turning Change Position Avoid Ulcers Patient Training
192786 - Training Change Position Bed Turning Avoid Ulcers Patient
192787 -
192788 - This the record the night after surgery, and seems to say the patient
192789 - was educated and encouraged to perform personal activities. This
192790 - seems profoma in that the patient had surgery on 091022 that ended OA
192791 - 1800, and slept until the next morning on 091023 0700.
192793 - ..
192794 - Progress Notes say in part...
192795 -
192796 - 1. LOCAL TITLE: NURSING ICU PICIS NOTE STANDARD TITLE: CRITICAL
192797 - CARE UNIT NOTE DATE OF NOTE: OCT 22, 2009@07:20:26 ENTRY DATE:
192798 - OCT 22, 2009@07:20:26 AUTHOR: DUNN,BENNIE T JR EXP COSIGNER:
192799 - URGENCY: STATUS: COMPLETED, ref DRT 1 9933
192801 - ..
192802 - 2. 022 Braden Assessments/Interventions. Provide pt/other
192803 - education regarding causes/prevention of pressure ulcers.
192804 - Teach pt/other importance to change position frequently for
192805 - pressure ulcer prevention. Encourage small, frequent position
192806 - changes. Turn/reposition every 2 hours while in bed, pillows
192807 - separating pressure areas. Avoid turning/position on side at
192808 - greater than 30 degree angle. Encourage activity as tolerated.
192809 - Perform ROM exercises when turning/repositioning. Limit
192810 - sitting out of bed to less than two hours at a time. Maintain
192811 - clean and dry skin. Apply protective barrier ointment.
192812 - Schedule toileting. Instruct pt/other to request assistance as
192813 - needed. Encourage meals and assist with meals as needed.
192814 - Provide or encourage oral care as needed. Monitor fluid/food
192815 - intake. Use a bed trapeze or pull sheet to lift up in bed or
192816 - turn. Raise the knee when elevating HOB. Keep HOB at or below
192817 - 30 degrees when not eating. Elevate HOB for meals, then, lower
192818 - within 1 hour after eating (10/21 8:00 PM) [...reported,
192819 - ref DRT 1 4G5H
192820 -
192821 -
192822 -
192823 -
192825 - ..
192826 - Heart Surgery Discharge Summary 091104
192827 - Discharge Summary of Care Surgery Heart CABG 4X
192828 -
192829 - Joe prepared a progress note cosigned by Elaine, summarizing care
192830 - for CABG....
192831 -
192832 - 1. LOCAL TITLE: Discharge Summary...................... ref DRT 1 VP3I
192833 - ADMIN DATE: OCT 21, 2009 DISCH. DATE: NOV 04, 2009
192834 - STANDARD TITLE: DISCHARGE SUMMARY
192835 - DICT DATE: NOV 04, 2009 ENTRY DATE: NOV 05, 2009@08:23:10
192836 - DICTATED BY: ENAYATI,JOSEPH ATTENDING: TSENG,ELAINE
192837 - URGENCY: routine STATUS: COMPLETED
192839 - ..
192840 - 2. DIAGNOSIS: Coronary artery disease.
192842 - ..
192843 - 3. DATE OF PROCEDURE: 10/22/09
192845 - ..
192846 - 4. PROCEDURE: Coronary artery bypass grafting.......... ref DRT 1 XUQW
192848 - ..
192849 - 5. HOSPITAL COURSE: The patient was admitted on 10/22/09 for
192850 - coronary artery bypass grafting. During his recovery, his
192851 - chest tube was taken out, and the patient had an episode of A
192852 - fib, which converted him to sinus rhythm. It was noted on
192853 - chest x-rays that he had a left pleural effusion, and this was
192854 - tapped at the bedside, resulting in a 600 cc tap. The patient
192855 - received Ensure per Nutrition recommendations for his poor
192856 - nutritional status secondary to chronic achalasia. ref DRT 1
192857 - XURP
192859 - ..
192860 - Incidentally noted on a chest CT was a right internal jugular
192861 - thrombus, and the patient was anticoagulated from thereon per a
192862 - vascular surgery consult. ref DRT 1 L55O
192864 - ..
192865 - He also received a feeding tube to try to improve his
192866 - nutritional status towards receiving a Heller myotomy as an
192867 - outpatient with Dr Stewart. Per the patient's request, the
192868 - feeding tube was discontinued, and a serial complete blood
192869 - count revealed an increasing white blood cell count, and he was
192870 - started on antibiotics. Antibiotics were to be continued for
192871 - ten days after his discharge. No source of infection was
192872 - identified though he did have on CT left lower lobe pleural
192873 - effusion and lung atelectasis. He will be followed as an
192874 - outpatient by Cardiothoracic Surgery and General Surgery for a
192875 - planned Heller myotomy in December. After review of the
192876 - patient's labs, physical exam and hospital course, he was
192877 - discharged home in stable condition on 11/04/09. ref DRT 1 XURP
192879 - ..
192880 - 6. PROBLEMS:............................... ref DRT 1 S59J
192881 -
192882 - 1. Coronary artery disease - Patient underwent coronary
192883 - artery bypass grafting and towards the end of his
192884 - hospital course he was cardiovascularly and
192885 - hemodynamically stable and in normal sinus rhythm.
192886 - ref DRT 1 S59J
192888 - ..
192889 - 2. Achalasia - The patient is being followed by General
192890 - Surgery for a planned Heller myotomy. At this point,
192891 - there is some risk of aspiration, which the patient is
192892 - aware of, and we recommend he continue his full liquid
192893 - diet supplemented with Ensure throughout the day to try
192894 - to improve his nutritional status. ref DRT 1 754H
192896 - ..
192897 - 7. DISCHARGE MEDICATIONS/DISCHARGE INSTRUCTIONS/WOUND
192898 - CARE/FOLLOW-UP INSTRUCTIONS:................. ref DRT 1 C74O
192900 - ..
192901 - Please refer to the discharge instructions note. The patient
192902 - has a follow-up cardiothoracic appointment on 11/19/09 at 10
192903 - a.m. and a General Surgery appointment with Dr. Stewart on
192904 - 11/17/09 at 1:40 p.m.
192906 - ..
192907 - 8. KJC/PSI...................................... ref DRT 1 T75L
192908 - DATE DICTATED: 11/04/09
192909 - DATE TRANSCRIBED: 11/04/09
192910 - JOB: 963515
192911 -
192922 -
192923 -
192925 - ..
192926 - Examination CABG Post Surgery Patient Doing Well
192927 -
192928 - Medical chart reports meeting with CT Surgery team on 091119...
192930 - ..
192931 - 1. LOCAL TITLE: CARDIOTHORACIC CLINIC F/U (SURG)......... ref DRT 1 TV4H
192932 - STANDARD TITLE: SURGERY OUTPATIENT NOTE
192933 - DATE OF NOTE: NOV 19, 2009@11:17 ENTRY DATE: NOV 19, 2009@11:18:01
192934 - AUTHOR: KUBAT,ERIC P EXP COSIGNER:
192935 - URGENCY: STATUS: COMPLETED
192937 - ..
192938 - 2. The supervising practitioner of record for this patient care
192939 - encounter is Dr Ratcliffe.
192941 - ..
192942 - 3. 64M s/p CABG 4-V 10/22 with a postop course complicated by
192943 - achalasia findings, difficulty maintaining nutrition, RIJ
192944 - thrombus and leukocytosis. He was d/c to home 11/4 on PO
192945 - ciprofloxacin, which he has completed. Currently he is walking
192946 - 3-4 miles a day. He denies CP, SOB, chest tightness,
192947 - palpitations. He denies d/c, erythema, pain at his incision
192948 - sites. No f/c. He has been taking Ensure daily for nutrition.
192950 - ..
192951 - 4. Vitals were good for meeting on 091119. ref DRT 1 MY7Y
192953 - ..
192954 - 5. A/P Doing well s/p CABG................... ref DRT 1 4896
192955 - -Finish course of amiodarone in 3 days
192956 - -Continue sternal precautions
192957 - -Coumadin per anticoag clinic, last INR 1.5 and 2/3 mg dosing
192958 - -F/U with Gen Surg 12/8 re: achalasia, possible heller myotomy
192959 - -Continue Ensure, last alb 3.5
192960 - -F/U CT surg 4 weeks with cbc, ekg, cxr
192962 - ..
192963 - VA Work plan for follow up examination in 4 weeks aligns with the
192964 - record meeting the team today, reported on 091119 1000. ref SDS 12
192965 - FW6W
192966 -
192967 - [...below, no record in medical chart of follow up meeting
192968 - at VA on 091219. ref SDS 0 5S6H
192970 - ..
192971 - D/W Dr. Cambronero
192972 - /es/ Eric Kubat, MD
192973 - R3, Surgical Service
192974 - Signed: 11/19/2009 17:46
192975 -
192976 -
192978 - ..
192979 - Commend VA Medical Practice Health Care Cardiology Surgery
192980 -
192981 - The medical chart for 091106, shows customer commended VA for good
192982 - work in this case...
192983 -
192984 - LOCAL TITLE: NURSING DISCHARGE F/U PHONE CALL NOTE........... ref ed 0 E73F
192985 - STANDARD TITLE: NURSING TELEPHONE ENCOUNTER NOTE
192986 - DATE OF NOTE: NOV 06, 2009@11:15 ENTRY DATE: NOV 06, 2009@11:15:56
192987 - AUTHOR: KEENAN,ALICE EXP COSIGNER:
192988 - URGENCY: STATUS: COMPLETED
192989 - Nursing Post Discharge Call
192991 - ..
192992 - Additional Comments: Vet had many positive comments
192993 - regarding the care he received. ref DRT 1 R57I
192994 -
192995 -
192996 -
192997 -
1930 -
SUBJECTS
Default Null Subject Account for Blank Record
2003 -
200401 - ..
200402 - Consent Surgery Heller Myotomy Recover Achalasia
200403 - Achalasia Consent Surgery Heller Myotomy Recover
200404 -
200405 - Document explaining informed consent....
200406 -
200407 - 1. LOCAL TITLE: INFORMED CONSENT NOTE.............. ref DRT 1 R19K
200408 - STANDARD TITLE: CONSENT
200409 - DATE OF NOTE: DEC 08, 2009@14:38:49 ENTRY DATE: DEC 08, 2009@14:39:38
200410 - AUTHOR: TABRIZI,RANNA MD EXP COSIGNER:
200411 - URGENCY: STATUS: COMPLETED
200413 - ..
200414 - This document is submitted twice in the VA's report, also listed.
200415 - ref DRT 1 YU6O
200417 - ..
200418 - LOCAL TITLE: INFORMED CONSENT NOTE continues...
200419 -
200420 - 2. Signature Informed Consent for................. ref DRT 1 0X4H
200421 -
200422 - ESOPHAGUS - FUNDOPLICATION (LAPAROSCOPIC) (FUNDOPLICATION (LAPAROSCOPIC))
200423 - ESOPHAGUS - HELLER MYOTOMY (HELLER MYOTOMY (OPEN ABDOMINAL))
200424 -
200425 - 1. Anatomical Location: See description of treatment/procedure.
200427 - ..
200428 - 2. Informed consent was obtained at 2:38 PM on December 08,
200429 - 2009. The full consent document can be accessed through
200430 - Vista Imaging. ref DRT 1 WZ5F
200432 - ..
200433 - 3. Patient name:
200435 - ..
200436 - 4. The patient HAS decision-making capacity.
200438 - ..
200439 - 5. Surrogate (if applicable):
200441 - ..
200442 - 6. Condition or diagnosis: Gastroesophageal Reflux Disease
200443 - (GERD). This is a digestive condition in which stomach
200444 - acid flows back into the esophagus (eh-SOF-uh-gus), the
200445 - long tube that connects the mouth to the stomach, with or
200446 - without hiatal hernia (a condition in which part of the
200447 - stomach pokes through the opening of the diaphragm into the
200448 - chest). ref DRT 1 L15M
200450 - ..
200451 - Difficulty swallowing.......................... ref DRT 1 B46K
200453 - ..
200454 - 7. Treatment/procedure: FUNDOPLICATION (LAPAROSCOPIC)
200455 -
200456 - Using a laparoscope (telescope with a small camera
200457 - attached), rebuilding of the muscle that lies at the base
200458 - of the esophagus to prevent acid from washing back into the
200459 - esophagus, with possible repair of hiatal hernia
200460 - (tightening of the esophageal opening of the diaphragm with
200461 - stitches or staples) and possible need to lengthen
200462 - esophagus with stapling of upper stomach. (collis
200463 - gastroplasty)(laparoscopic fundoplication)
200465 - ..
200466 - HELLER MYOTOMY (OPEN ABDOMINAL)
200468 - ..
200469 - The patient is admitted to the hospital, and the surgery is
200470 - performed in the operating room. General anesthesia
200471 - (unconsciousness caused by drugs) is used to keep the
200472 - patient pain-free.
200474 - ..
200475 - Five or six small incisions (surgical cuts) are made on the
200476 - abdominal wall, and a laparoscope (thin, tubular, lighted
200477 - instrument for viewing the abdominal and pelvic organs) is
200478 - inserted into the area around the stomach.
200480 - ..
200481 - After the lower end of the esophagus is found and moved
200482 - into position, the muscular ring surrounding the sphincter
200483 - muscle is cut, allowing it to open more easily. ref DRT 1
200484 - P77F
200486 - ..
200487 - This procedure seems conflicting with understandings on scope of
200488 - surgery and repair of achalasia problem, presented during the meeting
200489 - at the VA on 091030 0810. ref SDS 9 GM5I
200491 - ..
200492 - LOCAL TITLE: INFORMED CONSENT NOTE continues...
200493 -
200494 - When the procedure is complete, the incisions are closed.
200495 - A firm, elastic dressing (a cloth covering for a wound or
200496 - surgical cut) is applied. Once the procedure has been
200497 - completed, the patient is taken to the recovery room.
200498 - ref DRT 1 F47K
200500 - ..
200501 - FUNDOPLICATION (LAPAROSCOPIC)
200502 - HELLER MYOTOMY (OPEN ABDOMINAL)
200504 - ..
200505 - 8. An anesthesia practitioner will be involved in this
200506 - treatment/procedure.
200508 - ..
200509 - 9. Consent to Blood Products (if applicable):, ref DRT 1 N58M
200511 - ..
200512 - 10. Practitioner obtaining consent: Tabrizi,Ranna MD (FELLOW)
200514 - ..
200515 - 11. Supervising practitioner: Stewart,Lygia (STAFF-PHYSICIAN)
200516 - Practitioner(s) performing or supervising
200517 - treatment/procedure (if not listed above):
200519 - ..
200520 - 12. Witness Name: Mildred Buck, ex-wife
200522 - ..
200523 - 13. Comments:
200524 -
200525 - Laparoscopic Heller Myotomy, Dor fundoplication
200526 - *** SCANNED DOCUMENT ***
200527 - SIGNATURE NOT REQUIRED
200529 - ..
200530 - Electronically Filed: 12/08/2009
200531 - by: IMEDCONSENT GENERIC
200532 -
200533 -
200534 -
200536 - ..
200537 - Achalasia Patient History Swallowing Disorder Justify Surgery Consent
200538 - Heller Myotomy Surgery Informed Consent Recover Swallowing Disorder
200539 - Informed Consent Heller Myotomy Surgery Recover Swallowing Disorder
200540 - Swallowing Disorder Informed Consent Recover Heller Myotomy Surgery
200541 -
200542 - Operation Report in the medical chart for Heller Myotomy procedure on
200543 - 091216, 091216 0600, ref SDS 14 KE9U, and provides detailed account of
200544 - surgery procedures. ref DRT 1 YX6L
200546 - ..
200547 - Clinical Indications says in part...
200548 -
200549 - This is a 64-year-old man who has had a four- year history
200550 - of achalasia. He is able to tolerate liquids but
200551 - regurgitates solid food. Previously he had a manometry
200552 - that was consistent with achalasia. He also had an
200553 - esophagram that showed dilated esophagus up to
200554 - approximately 9 cm with at the lower esophageal sphincter.
200555 - ref DRT 1 T46N
200557 - ..
200558 - This section should cite the record showing actual patient history
200559 - shown on 090908 1130. ref SDS 4 FT6M, presented to Doctor Tseng and
200560 - the cardio thoracic surgery team meeting at the VA in San Francisco on
200561 - 091021 0716, ref SDS 5 LJ7L, and later presented to Doctor Stewart
200562 - while recovering from heart surgery and to evaluate prescribing Heller
200563 - Myotomy surgery for recovering from achalasia, reported on 091030
200564 - 0810. ref SDS 9 025I
200566 - ..
200567 - This section should also expressly cite endoscopy test to verify
200568 - patient has no esophageal afflictions, like cancer, that prevent
200569 - having Hellr Myotomy surger on LESV, was reviewed with Doctor Stewart
200570 - again on 091208 1300. ref SDS 13 U46G, citing procedure at VA in
200571 - Martinez on 051209 1130. ref SDS 2 PRRT, and another at VA in
200572 - Sacramento 3 months later on 060330 0712. ref SDS 3 CX8J, and further
200573 - manometry test also performed the same day by Doctor Lee at VA Medical
200574 - Center in Sacramento, reported on 060330 0712. ref SDS 3 MC7P
200576 - ..
200577 - Clinical Indications further says in part...
200578 -
200579 - Risks, benefits, and alternatives were discussed with the
200580 - patient regarding laparoscopic Heller myotomy and Dor
200581 - fundoplication and after all questions were answered,
200582 - informed consent was obtained. ref DRT 1 T46N
200584 - ..
200585 - The Operation Report does not show what benefits and alternatives were
200586 - presented to the patient, nor when discussion occurred, what questions
200587 - were asked and what answers were given that justified approval for
200588 - surgery rather than alternatives. There is no reference in this part
200589 - of the medical chart to meeting with the doctor in the Telemetry
200590 - Department while recovering from heart surgery. At that time, the
200591 - doctor submitted a diagram showing scope of work and indicated high
200592 - expectations for a permanent solution, relative to alternatives using
200593 - pneumatic dilation, reported on 091030 0810. ref SDS 9 P69G
200594 -
200595 -
200596 -
200597 - Surgery Heller Myotomy Recover Achalasia Swallowing Disorder
200600 - Heller Myotomy Surgery Laproscopic Procedure Recover Achalasia
200601 -
200602 - Details of surgery are reported in Progress Notes. ref DRT 1 4W6H
200603 -
200604 - We therefore made a curvilinear, superior umbilical
200605 - incision, which is carried down to the fascia. Veress
200606 - needle was inserted and a drop test was passed. The
200607 - abdomen was insufflated under low flow with low pressures
200608 - and then turned up to high flow. An 11 mm trocar was
200609 - introduced and inspection with a laparoscope showed no
200610 - trauma from the placement of this trocar. We then placed a
200611 - left subcostal 11 mm port under direct vision using a
200612 - blade-less trocar. A mirror image port was placed on the
200613 - right subcostal region and then a right lateral 11 mm port
200614 - was placed as well as a left lateral upper quadrant port
200615 - under direct vision. With all these port sites a blend of
200616 - 1% Lidocaine and 0.5% Marcaine and epinephrine was
200617 - infiltrated into the skin and along the peritoneum. The
200618 - left lateral segment of the liver was retracted using a
200619 - liver retractor. ref DRT 1 M84N
200621 - ..
200622 - We began our dissection by dividing the gastrohepatic
200623 - ligament at the transparent portion using a harmonic
200624 - scalpel. This was then taken up over the GE junction and
200625 - the peritoneum over this was divided transversely towards
200626 - the left until we were over the left crus. Using gentle
200627 - blunt dissection the esophagus was carefully dissected free
200628 - from the right crus. ref DRT 1 4W6H
200630 - ..
200631 - We then turned our attention to dividing the short gastric
200632 - vessels. This was done with harmonic scalpel taking care
200633 - not to injure the greater curvature of the stomach. This
200634 - was carried out along the length of the greater curvature
200635 - over the fundus until reaching the previous dissection of
200636 - the left crus. The GE junction was then carefully
200637 - dissected free from the left crus until it was clear that
200638 - the fundus could be wrapped all the way over towards the
200639 - right crus without tension. ref DRT 1 Q96O
200641 - ..
200642 - The fat pad over the gastroesophageal junction was
200643 - carefully dissected off using the harmonic scalpel and
200644 - excised. This exposed the gastroesophageal junction. We
200645 - then carefully dissected out the distal esophagus up to
200646 - where we thought the myotomy would end. ref DRT 1 7J3O
200648 - ..
200649 - We then performed Heller myotomy using electrocautery.
200650 - First, the GE junction was identified and the longitudinal
200651 - fibers were divided with cautery. 5 cm proximally to the
200652 - distal esophagus and 2 cm distally onto the cardia on the
200653 - anterior aspect of the esophagus and stomach. We then took
200654 - this dissection one layer deeper down to circular muscle
200655 - fibers. Care was taken not to disrupt the mucosa, however,
200656 - at the GE junction a small enterotomy was made. We
200657 - immediately suctioned out the obvious contents that were
200658 - present with minimal spillage. This enterotomy was closed
200659 - with a 2-0 silk EndoStitch and another 3-0 silk
200660 - intracorporeal suture. We tested this repair by
200661 - insufflating this region with air through the oral gastric
200662 - tube after submerging the repair under irrigation and there
200663 - was no evidence of leakage. ref DRT 1 KJ4K
200665 - ..
200666 - We then performed a Dor myotomy starting on the left side.
200667 - The fundus was approximated to the left crus and then the
200668 - left edge of the myotomy using three interrupted 2-0
200669 - Surgidac EndoStitches. We then applied to seal glue over
200670 - the enterotomy and along the myotomy. We then completed
200671 - the right side of the fundoplication by bringing the edge
200672 - of the fundus back over towards the right crus and re-
200673 - approximating the fundus to the right edge of the myotomy
200674 - and then the right crus using three interrupted 2-0
200675 - Surgidac. We completed the closure at the apex of this
200676 - fundoplication using a single 2-0 Surgidac and then
200677 - extended the inferior portion of the right side of the
200678 - fundoplication using another suture of the fundus to the
200679 - right crus alone. We then carefully irrigated and
200680 - suctioned the left upper quadrant around the area of the
200681 - spleen where there was a small amount of spillage. We also
200682 - irrigated over the caudate lobe. ref DRT 1 VK8F
200683 -
200684 - [On 150319 0800 meeting with Doctor Lee indicated acid
200685 - reflux increased causing ulceration and constriction to
200686 - LESV that hampers swallowing, because fundoplication has
200687 - unraveled, ref SDS 28 N535; remedy - referral to Doctor
200688 - Stewart to assess re-fundoplication or other measures.
200689 - ref SDS 28 JQ5J
200691 - ..
200692 - The fascia was then closed at the umbilical port after the
200693 - abdomen had been desufflated using a Carter Thompson, a
200694 - needle passer, and a figure-of-eight 0 Maxon suture. The
200695 - remaining ports were then removed under direct vision
200696 - without evidence of Bleeding. Skin was closed at all port
200697 - sites using running 4-0 subcuticular Monocryl after
200698 - irrigating the sites with antibiotic irrigation. Sterile
200699 - dressings were then applied. ref DRT 1 MM9L
200700 -
200701 -
200702 -
200703 -
200704 -
200705 - <5S5L
200706 - <5S5L
200707 - Surgery Heller Myotomy Details of Physicians Nurses and Times
200708 -
200709 - There is another extensive recored shown. ref DRT 1 EP5F
200710 -
200711 -
200712 -
200713 - Achalasia Barium Swallow Test Esophagus after Heller Myotomy Surgery
200716 - Swallow Test Radiology Gastrografin Barium Contrast Post Heller Myotomy
200717 - Heller Myotomy Swallow Test Radiology Gastrografin Barium Post Surgery
200718 - Radiology Barium Swallow Test Esophagus Post Heller Myotomy Surgery
200719 -
200720 - Two days after Heller Myotomy surgery, per above, ref SDS 0 SO4N, the
200721 - VA performed radiology swallow test with Gastrografin similar to
200722 - barium swallow test that diagnosed achalasia originally performed on
200723 - 050714. 050714 1000, ref SDS 1 2I9J The original test showed severely
200724 - distorted lower esophagus and constricted sphincter valve (LESV).
200725 - ref SDS 1 B94J
200727 - ..
200728 - The test today used Gastrographin for barium contrast medium.
200729 - ref DRT 1 T49H
200731 - ..
200732 - FINDINGS - Bird Beak Dilation Persistent Narrowing Achalasia
200733 -
200734 - 1. Scout view of the abdomen demonstrates median sternotomy
200735 - wires and surgical clips in the region of the stomach.
200736 - ref DRT 1 3G6M
200738 - ..
200739 - 14. Beak-like configuration of the distal esophagus with
200740 - persistent narrowing of the gastroesophageal junction may
200741 - be due to postoperative edema. Dilatation of the more
200742 - proximal esophagus is compatible with history of achalasia.
200743 - ref DRT 1 GC3I
200745 - ..
200746 - 15. Contrast slowly flows into the stomach and readily empties
200747 - into the duodenum. No contrast leak is seen. ref DRT 1
200748 - JC3O
200750 - ..
200751 - This report does not expressly compare with prior barium swallow test,
200752 - which found severe distortion of esophageal and a long string-like
200753 - structure leading to the stomach which severely restricts swallowing,
200754 - reported on 050714 1000. ref SDS 1 2I9J
200756 - ..
200757 - Finding "Beak-like configuration and dilation of proximal esophagus
200758 - with persistent narrowing of gastroesophageal junction may correlate
200759 - with original findings on 050714 1000. ref SDS 1 B94J
200761 - ..
200762 - Since benefits of surgery acrue slowly over weeks and months, the
200763 - esophageal condition on 091218, just 2 days after surgery on 091216,
200764 - to correct achalasia swallowing disorder, would be much worse than 4.5
200765 - years earlier on 050714 1000. ref SDS 1 B94J Presenting this
200766 - comparison in the test impression would help guide assessment of
200767 - patient recovery from swallowing disorder.
200768 -
200769 - [On 130117 0900 barium swallow CT test shows significant
200770 - improvement compared to original condition on 050714,
200771 - ref SDS 1 B94J - there is no big bulge and no long
200772 - string-like structure preventing content from flowing into
200773 - the stomach. ref SDS 27 OH6G
200775 - ..
200776 - [On 150527 0930 VA Medical Center in San Francisco
200777 - performed another CT Barium Swallow test - preliminary
200778 - results are favorable indicating patient has not suffered
200779 - recurrent achalasia symtom of distorted esophagus, commonly
200780 - called "bird beak," rather esophagus looks normal.
200781 - ref SDS 29 V56N
200782 -
200784 - ..
200785 - Discharge surgery achalasia 091220. ref DRT 1 V519
200786 -
200787 -
200789 - ..
200790 - Meeting Mark Ratcliff Neal Camberono and CT Team No Record
200791 -
200792 - Cannot find any record of meeting with medical team in TCU post Heller
200793 - Myotomy surgery on 091219 0600. ref SDS 15 0M6S
200795 - ..
200796 - Meeting with the medical team on 091119, ref DRT 1 4896, cites work
200797 - plan for follow up examination in 4 weeks.
200799 - ..
200800 - Where is VA's record for follow up examination with CT surgery team?
200801 -
200802 -
200803 -
200804 -
200805 -
200806 -
200807 -
200808 -
200809 -
200810 -
200811 -
2009 -