CONTACTS
SUBJECTS
VA EGD Procedure Dilate Stricture Lower Esophageal Sphincter Valve L
5203 -
5203 - ..
5204 - Summary/Objective
5205 -
520501 - Follow up ref SDS 90 0000. ref SDS 87 0000.
520502 -
520503 -
520504 -
520505 -
520507 - ..
5206 -
5207 -
5208 - Background
5209 -
520901 - On 101210 EGD procedure dilated esophageal sphincter valve from 11 to
520902 - 14 mm. EGD today dilate from 14 to 17 mm. ref SDS 66 BF6L
520904 - ..
520905 - Test today was schedule in VA's letter dated 101210, received on
520906 - 101214 2330. ref SDS 68 ZG7O
520908 - ..
520909 - On 101216 1021 letter commends medical team for excellent work, and
520910 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
520912 - ..
520913 - On 110218 0730 4th EGD dilation at VA in Martinez, 110218 0730,
520914 - ref SDS 73 SR8M, and using anesthesia with Fentanyl. ref SDS 73 SR5O
520916 - ..
520917 - On 110429 0830 5th EGD dilation at VA in Martinez, 110429 1230,
520918 - ref SDS 78 NU8L, and using anesthesia with Fentanyl. ref SDS 78 SR5O
520919 - Good results dilating stricture in LESV to "ring finger," Next EDG
520920 - dilation ordered in 3 months, on 110729 0730. ref SDS 78 LJ6J
520922 - ..
520923 - On 110607 1414 visited GI Department, ref SDS 82 HC5H, and Charlene
520924 - reported a computer mistakes requires scheduling next EGD dilation on
520925 - 110819 0830. ref SDS 82 N642 Requested meeting with Doctor Lee
520926 - to review pending action items. ref SDS 82 4P6J,
520928 - ..
520929 - 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter
520930 - valve. ref SDS 87 K37G
520931 -
520932 - 111115 1300 EGD and Dilation structure lower esphageal sphincter
520933 - valve (LESV), after 5 months. ref SDS 90 K37G
520934 -
520935 - 120322 1030 EGD and Dilation structure lowere esphageal sphincter
520936 - valve (LESV), after 5 months. ref SDS 0 K37G
520937 -
520938 -
520939 -
520940 -
520942 - ..
5210 -
5211 -
5212 - Progress
521301 - ..
521302 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
521303 - GI Department VA Sacramento Medical Center Administration EGD Dilation
521304 -
521305 - Follow up ref SDS 90 NU8L, ref SDS 87 NU8L.
521306 -
521307 - Applied pre-proc requirements for NPO after midnight, from letter on
521308 - 101015 1547. ref SDS 54 6F8M Last liquid was on 120321 1830, and
521309 - last food was at 120321 1500.
521311 - ..
521312 - Stayed at Kathy's place last night in Sacremento. She drove us to
521313 - the VA Medical Center at Mather AFB.
521315 - ..
521316 - Checked into GI Department at the customer counter.
521318 - ..
521319 - Submitted Kathy's cell phone for designated driver.
521323 - ..
521324 - Kathy signed the discharge form affirming she will be designated
521325 - driver, and responsible to facilitate no driving for 24 hours.
521327 - ..
521328 - Nurse at customer counter asked questions on patient history to verify
521329 - ready for procedure, e.g., no allergies, and NPO after midnight to
521330 - avoid conflicts with anesthesia; no health problems, e.g., no
521331 - diabetes, alcohol, cigarettes.
521333 - ..
521334 - Waited in lobby for 5 minutes. Another nurse called the patient into
521335 - a meeting.
521336 -
521338 - ..
5214 -
5215 -
5216 - 1042
5217 -
521701 - Kathy joined this meeting in a small office adjacent to the check-in
521702 - counter.
521704 - ..
521705 - The nurse took vitals...
521706 -
521707 - Weight.................. 192
521708 - BP...................... 131 80
521709 - Temp.................... 97.8
521711 - ..
521712 - Initial blood pressure was very high, about 140 86. Since this
521713 - conflicts with recent patient history the past week, beginning on
521714 - 120318, and reported in case study on 101010 0744, ref SDS 52 PH8L,
521715 - blood pressure was taken again and reported consistent with recent
521716 - patient hisotry.
521718 - ..
521719 - The nurse asked further background on patient history, repeating and
521720 - extending questions presented during check-in, per above. ref SDS 0
521721 - ML8O
521722 -
521723 -
521724 -
5218 -
SUBJECTS
Default Null Subject Account for Blank Record
5303 -
5304 - 1042
530501 - ..
530502 - Signature Requested Blank Form on Understanding Discharge Instructions
530503 -
530504 - Follow up ref SDS 90 SR8M, ref SDS 87 SR8M.
530506 - ..
530507 - After completing vitals and another review of patient history, per
530508 - above, ref SDS 90 487K, Nurse requested signature and date on a form...
530509 -
530510 - GI Discharge Instructions
530512 - ..
530513 - This is the form Kathy signed earlier and entered her cell phone
530514 - number to identify the designated driver, per above. ref SDS 90 J355
530516 - ..
530517 - The form showed the patient's name and address at the bottom, and had
530518 - no instructions since there has not yet been an examination and the
530519 - procedures have not yet been performed.
530521 - ..
530522 - Asked about signing a blank form with no date acknowledging notice of
530523 - communications on the procedure and discharge instructions?
530525 - ..
530526 - The nurse said to sign the form and enter the date. He explained VA
530527 - procedure for patient to sign blank forms acknowledging receipt of
530528 - instructions which are not actually entered on the document. The
530529 - nurse said that after medical care is provided today, the patient will
530530 - get a copy of this pre-signed "Discharge Instructions" form with
530531 - instructions by the doctor on medications, and findings from medical
530532 - procedures. This aligns with prior VA guidance on 110429 1230.
530533 - ref SDS 78 IT7G
530535 - ..
530536 - Signed the blank discharge form.
530538 - ..
530539 - Could not find a place for entering the date.
530541 - ..
530542 - The nurse said to enter the date on the line above patient signature.
530544 - ..
530545 - Entered the date.
530546 -
530547 -
530548 - [...below on 120322 1030 at 1532 received blank Discharge
530549 - form without signature nor date. ref SDS 0 PR4S
530550 -
530551 - [On 120925 0900 reviewed challenge of signing blank
530552 - discharge documents before medical services are performed,
530553 - with Doctor Lee; decided to sign documents post-proc.
530554 - ref SDS 96 Z48H
530556 - ..
530557 - The nurse fastened patient ID plastic bracelet on left arm.
530559 - ..
530560 - Went back to the lobby. There was another wait for about 5 minutes.
530561 -
530563 - ..
5306 -
5307 -
5308 - 1048
5309 -
530901 - Lee, another nurse, called the patient for pre-op.
530903 - ..
530904 - Kathy left to attend her luncheon.
530906 - ..
530907 - Went through a locked door into OR area. Lee gave instructions to
530908 - dress down in a restroom.
530910 - ..
530911 - After changing into a hospital gown, went into another small office.
530913 - ..
530914 - Nurse Lee asked more questions similar to those already answered, when
530915 - the Discharge document was signed 10 minutes earlier, per above.
530916 - ref SDS 0 UH7M The nurse entered responses into the computer again.
530917 -
530918 -
530920 - ..
530921 - Consent Signed EGD Dilation and Meeting Review Pending Issues
530922 - Consultation Pending Issues and Sign Consent for EGD Dilation
530923 -
530924 - Follow up ref SDS 90 SR4G, ref SDS 87 SR4G.
530925 -
530926 - Doctor Lee arrived.
530928 - ..
530929 - Asked about his new daughter who was adopted last year when he and his
530930 - wife traveled to China in December to adopt. The doctor said the new
530931 - baby is doing well. They have an 11 year old daughter, so I made a
530932 - joke about using "lessons learned" on the first child to raise the new
530933 - baby.
530935 - ..
530936 - We reviewed record stopping Omeprazole on 111201, to avoid high blood
530937 - pressure, reported in case study on patient history for diet,
530938 - exercise, medications, and vitals listed in the record for 101010
530939 - 0744. ref SDS 52 734L, and further citing spreadsheet case study on
530940 - blood pressure changes over the past 18 months, also on 111201 0928.
530941 - ref SDS 91 ZM5H Research showing high blood pressure is an infrequent
530942 - side effect of Omeprazole was reported a year earlier on 101218 1642.
530943 - ref SDS 70 1J5G About 2 days later suffered severe negative response
530944 - from stopping Omeprazole entirely, so added 1 pill per day on 1101203,
530945 - reported in case study on 101010 0744, ref SDS 52 ZU8M
530947 - ..
530948 - [On 120326 1549 ordered refill Omeprazole.
530949 - ref SDS 94 5N3O
530951 - ..
530952 - Doctor Lee asked how blood pressure responded to changing from 4 pills
530953 - of Omeprazole totalling 80 mg per day, down to 20 mg taking 1 pill per
530954 - day?
530956 - ..
530957 - Patient history the past 4 months shows daily blood pressure declined
530958 - back to within approximately 115 - 130 over 65 - 75, shown in case
530959 - study on 101010. ref SDS 52 OF4N Blood pressure yesterday was...
530960 -
530961 - Wednesday Left Right Differential
530962 - 1018........................ 126 72 56 125 69 56 1 3 0
530963 - 1024........................ 119 64 54 127 66 53 -8 -2 1
530964 - 1028........................ 117 65 54 122 66 54 -5 -1 0
530965 - 1032........................ 119 65 53 112 66 54 7 -1 -1
530967 - ..
530968 - Blood pressure at the VA today, per above, ref SDS 0 487K....
530969 -
530970 - 1042........................ 131 80
530972 - ..
530973 - Discussed patient history of no evident stomach pain often called
530974 - "heart burn," and so asked how this aligns with getting treatment with
530975 - Omeprazole, repeating report during prior procedure on 111115 1300.
530976 - ref SDS 90 A76L There has been some noticable burping episodes
530977 - associated with eating.
530979 - ..
530980 - Doctor Lee explained stomach acid problems can occur without feeling
530981 - any symptoms, and that burping does signal mild stomach acid symptoms.
530982 - Evidence of stomach acid in this case is continuing stricture in LESV,
530983 - as related previously on 111115 1300. ref SDS 90 N266
530985 - ..
530986 - At that time, on 111115, Doctor Lee's assistant, Kendal, advised that
530987 - average healthy LESV diameter is 20 mm, and that Doctor Lee dilates
530988 - LESV to maximum below 20 mm. ref SDS 90 N341
530990 - ..
530991 - Additionally, on 111115, during the prior procedure, Doctor Lee
530992 - dilated LESV to 18 mm, but did not inject triamcinolone steriod
530993 - injection to LESV to resist contraction that aids swallowing and
530994 - reduces vomitting. ref SDS 90 IS6L Progress Notes report that adding
530995 - triamcinolone steriod injection to resist contraction of LESV was
530996 - effective to avoid severe swallowing and vomitting problems,
530997 - ref SDS 90 AW6J
530999 - ..
531000 - Swallowing Difficulties Increased Vomitting
531001 -
531002 - Follow up ref SDS 90 IS6L.
531003 -
531004 - Today, Doctor Lee asked about swallowing and vomitting since prior
531005 - procedure on 111115 1300. ref SDS 90 05HH
531007 - ..
531008 - Advised that difficulty swallowing has increased, since the prior EGD
531009 - dilation on 111115, when triamcinolone steriod was not injected into
531010 - the LESV to resist contraction, as reported in Progress Notes,
531011 - ref SDS 90 IS6L, and beginning on 111203, as shown in case study on
531012 - 101010 0744. ref SDS 52 ZU8M
531013 -
531014 - [...below on 120322 1030 Progress Notes report
531015 - triamcinolone steriod injection was not performed again
531016 - today. ref SDS 0 5179
531017 -
531018 - 20%.......... 111203, ref SDS 52 ZU8M
531019 - 5%.......... 111214, ref SDS 52 F68K
531020 - 5%.......... 111219, ref SDS 52 XY5V
531021 - 3%.......... 111221, ref SDS 52 2E7O
531022 - 5%.......... 111228, ref SDS 52 VP6H
531024 - ..
531025 - New study beginning on 120101, shows vomitting...
531026 -
531027 - 3%.......... 120102, ref SDS 92 225O
531028 - 5%.......... 120106, ref SDS 92 JZ5M
531029 - 5%.......... 120107, ref SDS 92 4Y4J
531030 - 5%.......... 120108, ref SDS 92 4T7I
531031 - 2%.......... 120110, ref SDS 92 3F6M
531032 - 3%.......... 120111, ref SDS 92 NI8K
531033 - 1%.......... 120112, ref SDS 92 YZ9L
531034 - 10%.......... 120119, ref SDS 92 ZZ4O
531035 - 15%.......... 120120, ref SDS 92 IP3J
531036 - 30%.......... 120125, ref SDS 92 FC6H
531037 - 10%.......... 120126, ref SDS 92 XS8H
531038 - 5%.......... 120127, ref SDS 92 KS4K
531039 - 5%.......... 120128, ref SDS 92 TL3J
531040 - 5%.......... 120129, ref SDS 92 QL6L
531041 - 2%.......... 120131, ref SDS 92 NH5H
531042 - 3%.......... 120201, ref SDS 92 IX4F
531043 - 4%.......... 120202, ref SDS 92 YE6M
531044 - 3%.......... 120203, ref SDS 92 YY8L
531045 - 3%.......... 120204, ref SDS 92 Z36F
531046 - 3%.......... 120205, ref SDS 92 IH5H
531047 - 6%.......... 120207, ref SDS 92 DV4M
531048 - 3%.......... 120216, ref SDS 92 ZI6K
531049 - 3%.......... 120217, ref SDS 92 7F9N
531050 - 2%.......... 120218, ref SDS 92 SZ5O
531051 - 4%.......... 120219, ref SDS 92 633J
531052 - 10%.......... 120302, ref SDS 92 R85I
531053 - 10%.......... 120303, ref SDS 92 RI4I
531054 - 90%.......... 120329, ref SDS 92 S96J
531056 - ..
531057 - Key question today is how much LESV contracted from 18 mm, since the
531058 - prior procedure injecting triamcinolone steriod was ended on 111115,
531059 - despite being effective resisting contraction of LESV, as stated in
531060 - Progress Notes on 111115. ref SDS 90 AW6J
531062 - ..
531063 - After the procedure, Progress Notes for today show...
531064 -
531065 - LESV Dilated
531066 - Date from - to
531067 - 120322 16.5 18...................... ref SDS 0 516N
531068 - 111115 16.5 18...................... ref SDS 90 IR57
531069 - 110819 15 16.5...triamcinolone.... ref SDS 87 J978
531070 - 110429 13 16.5...triamcinolone.... ref SDS 78 U23I
531071 - 110218 11 14.....triamcinolone.... ref SDS 73 AA5O
531072 - 101210 11 14...................... ref SDS 66 H347
531073 - 100827 11 15...................... ref SDS 49 JE6X
531074 - 100305 11 15...................... ref SDS 42 WR6L
531076 - ..
531077 - Explained patient goal to dilate LESV to 20 mm today.
531078 -
531079 - [...below on 120322 1030 Progress Notes report LESV
531080 - contracted to somewhere between 16.5 mm and 18 mm, since
531081 - prior dialation to 18mm, ref SDS 0 516N; LESV was dilated
531082 - to 18 mm today, and triamcinolone steriod was not injected
531083 - to resist contraction of LESV to resist contraction that
531084 - aids swallowing to prevent vomitting. ref SDS 0 5179
531086 - ..
531087 - [On 120330 1418 letter from Doctor Lee reports results of
531088 - EGD test today - dilated LESV to 18 mm, biopsies shows no
531089 - evidence of cancer, and finds esophagitis that requires
531090 - taking Omeprazole twice a day. ref SDS 95 8482
531091 -
531092 -
531093 -
5311 -
SUBJECTS
Default Null Subject Account for Blank Record
5403 -
540401 - ..
540402 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
540403 -
540404 - Follow up ref SDS 90 UN6K, ref SDS 87 UN6K.
540405 -
540406 - Lee took me to a bed.
540408 - ..
540409 - Lee was successful on 1st try getting blood flow for the IV needed to
540410 - provide sedation. She applied patient's suggestion to set the IV in
540411 - the left side of the inner right arm.
540413 - ..
540414 - This aligns with Iris's success setting an IV on the first try for the
540415 - procedure on 111115 1300, ref SDS 90 4Z9O, and further corrects prior
540416 - problems reported in study on 110429 1230. ref SDS 78 UN6K
540417 -
540418 -
540419 -
540420 -
5405 -
SUBJECTS
Default Null Subject Account for Blank Record
5503 -
5504 - 0913
550501 - ..
550502 - Lidocaine Applied Numb Throat for EGD Dilation
550503 -
550504 - Follow up ref SDS 90 PQWY.
550505 -
550506 - While still on the hospital bed, the procedure nurse (not Lee) came
550507 -
550508 - into the Pre-op area. He asked the patient to sit up on the bed and
550509 - applied Lidocaine to numb the throat, using an instrument that
550510 - squirted agent into the mouth, as explained in the record for the
550511 - prior procedure on 111115 1300. ref SDS 90 UO6L
550513 - ..
550514 - All pre-op and administration were performed with outstanding care
550515 - and professionalism, similar to prior experience at VA Martinez, and
550516 - at the Medical Center in San Francisco.
550517 -
550518 -
550520 - ..
550521 - OR EGD Dilation after 2nd Application Lidocaine
550522 - EGD Dilation Procedure in OR 2nd Application Lidocaine
550523 -
550524 - Follow up ref SDS 90 LE59.
550525 -
550526 - Was wheeled from pre-op into the OR.
550528 - ..
550529 - In the OR, there was a second application of Lidocaine to numb the
550530 - throat, as done previously, and citing the record for the earlier
550531 - procedure on 110429 1230. ref SDS 78 UO6L
550533 - ..
550534 - Then received Fentanyl and other drugs for conscious sedation, used
550535 - for anesthetic, reported in medical chart for procedure on 100827
550536 - 0738. ref SDS 49 JE9V
550538 - ..
550539 - For remainder of record see VA medical chart ordered after the
550540 - procedure, shown below.
550541 -
550542 -
550544 - ..
5506 -
5507 -
5508 - 1343
5509 -
550901 - Dilated 18 MM Rather than Healthy LESV 20 MM
550902 -
550903 - Awake in recovery.
550905 - ..
550906 - Doctor Lee met in the Recovery Room. Patient was still groggy from
550907 - anesthesia. Could not conduct comprehensive meeting, and so did not
550908 - discuss findings from the procedure, as done for prior procedures,
550909 - e.g., on 110819 0830. ref SDS 87 SS5N
550910 -
550911 - [On 120330 1418 letter from Doctor Lee reports results of
550912 - EGD test today - dilated LESV to 18 mm, biopsies shows no
550913 - evidence of cancer, and finds esophagitis that requires
550914 - taking Omeprazole twice a day. ref SDS 95 8482
550916 - ..
550917 - Additionally, forgot to discuss scheduling meeting with Doctor Stewart
550918 - to review results and adjustments following Heller Myotomy surgery on
550919 - 091216 0600, ref SDS 31 KE9U, and in relation to objectives set in the
550920 - meeting with the doctor on 091030 0810, ref SDS 19 6G4O, and confirmed
550921 - in a later meeting on 091208 1300. ref SDS 27 QB41
550923 - ..
550924 - Today, Doctor Lee prescribed increasing Omeprazole medication from 1
550925 - pill per day, set on 111201 to recover from high blood pressure side
550926 - effects, as discussed this morning, per above, ref SDS 0 UH5F, to
550927 - taking 1 pill twice a day (morning and evening meals). He feels
550928 - recovery from high blood pressure achieved by reducing Omeprazole from
550929 - 4 to 1 pill per day, justifies trying to increase Omeprazole back to 2
550930 - pills per day for better control acid reflux, which continues to cause
550931 - LESV strictures that impede swallowing, and so cause vomitting.
550933 - ..
550934 - Doctor Lee further prescribed scheduling the next procedure in 6
550935 - months.
550936 -
550937 - [On 120330 1418 letter from Doctor Lee reports results of
550938 - EGD test today - dilated LESV to 18 mm, biopsies shows no
550939 - evidence of cancer, and finds esophagitis that requires
550940 - taking Omeprazole twice a day. ref SDS 95 8482
550942 - ..
550943 - Went back to sleep for another few hours until Kathy arrived for the
550944 - drive home.
550945 -
550947 - ..
5510 -
5511 -
5512 - 1510
5513 -
551301 - The nurse, Susan, removed IV catheter.
551303 - ..
551304 - Kathy arrived. Dressed to leave.
551305 -
551306 -
5514 -
SUBJECTS
Default Null Subject Account for Blank Record
5603 -
5604 - 1513
560501 - ..
560502 - GI Discharge Instructions Comprehensive Handwriting Problematic
560503 -
560504 - Follow up ref SDS 90 PR4S, ref SDS 87 PR4S.
560505 -
560506 - Received documentation from Susan; there was no siguature, no date,
560507 - and no instructions. It was a blank form, despite having signed the
560508 - form during admittance, shown above. ref SDS 0 SR8M
560509 -
560510 - [On 120323 0748 next day went back to VA and exchanged the
560511 - blank form for a copy of the signed Discharge Instructions.
560512 - ref SDS 93 JU6L
560514 - ..
560515 - [On 120925 0900 reviewed challenge of signing blank
560516 - discharge documents before medical services are performed,
560517 - with Doctor Lee; decided to sign documents post-proc.
560518 - ref SDS 96 Z48H
560520 - ..
560521 - Susan advised that Doctor Lee told her results of the procedure and
560522 - change of prescription were explained to the patient, and so the VA
560523 - should give the patient a blank Discharge INstructions form.
560525 - ..
560526 - At this point, was still groggy and wobbly from anesthesia, so did
560527 - not insist on getting a copy of the document signed this morning, as
560528 - the nurse said would be done. Instead, went with Kathy to leave the
560529 - hospital for home.
560531 - ..
560532 - Received blank document similar to VA Form 10-9096, which says...
560533 -
560534 - Department Veterans Administration
560535 - VA Northern California Health Care System
560536 - Gastroenterology Department
560538 - ..
560539 - GI Discharge Instructions
560540 -
560541 - 1. Do not drive a motor vehicle, operate machinery or make
560542 - important decisions for at least 24 hours after the procedure.
560543 - The medictions given during the procedure may effect how you
560544 - act and think.
560546 - ..
560547 - 2. You may resume your usual diet after the procedure unless
560548 - instructed otherwise.
560550 - ..
560551 - 3. You may experience some abdominal bloating, cramping or gas.
560552 - Walking around the house or drinking warm weak tea or black
560553 - coffee may help.
560555 - ..
560556 - 4. You might have a mild sore throat following an EGD which can be
560557 - relieved by gargling with warm salt water.
560559 - ..
560560 - Nurse circled #4 with blue ink. Did not notice soreness in the
560561 - throat.
560563 - ..
560564 - Discharge instructions continue...
560565 -
560566 - 5. Continue all medications as directed and begin new medications
560567 - as prescribed.
560568 -
560569 - 6. Do not take aspirin, products containing aspirin, or
560570 - anti-inflammatory agents (i.e., Motrin, Advil, etc) for the
560571 - next *** OK today *** days.
560573 - ..
560574 - Nurse wrote with red ink "OK today" in the blank.
560576 - ..
560577 - Discharge instructions continue...
560578 -
560579 - 7. Warfarin Coumadin Patients
560581 - ..
560582 - Nurse circled #7 and drew a line with blue ink pen through it,
560583 - reflecting patient is not taking these medications.
560585 - ..
560586 - Discharge instructions continue...
560587 -
560588 - 8. If you have any of the following symptoms, please call the
560589 - clinic checked below for advice....
560590 -
560591 - Mon - Fri......................... 925 372 2000 ext 5168
560592 - Weekends Holidays................. 800 382 8387
560593 -
560594 - A. Passing or vomitting a large amount of blood.
560595 - B. Passing black or tarry stools.
560596 - C. Fever over 100 degrees with or without chills.
560598 - ..
560599 - D. Severe inflammation at the needle puncture site.
560601 - ..
560602 - Next day mild inflammation occurred at the two failed IV catheter
560603 - sites, explained above, ref SDS 78 124H, so not severe enough to
560604 - require care. May be "canary in the mine" portending future concern.
560606 - ..
560607 - Discharge instructions continue...
560608 -
560609 - E. Severe abdominal or chest pain.
560610 - F. Shortness of breath or tightness in your chest.
560611 - G. Loss of consciousness or frequent dizziness.
560612 - H. Emergency go to nearest hospital or dial 911.
560614 - ..
560615 - 9. Additional instructions (i.e., Sitz Bath, Medications, etc)
560617 - ..
560618 - For some reason, the Discharge Instructions provide no explanation of
560619 - findings from the procedure today, nor instructions, which was done
560620 - for the prior procedure on 111115 1300. ref SDS 90 DU6J
560621 -
560622 - [On 120323 0748 next day went back to VA and exchanged the
560623 - blank form for a copy of the signed Discharge Instructions,
560624 - and Susan wrote the doctor's instructions to take 1 pill
560625 - twice a day with meals. ref SDS 93 JU6L
560627 - ..
560628 - [On 120330 1418 letter from Doctor Lee reports results of
560629 - EGD test today - dilated LESV to 18 mm, biopsies shows no
560630 - evidence of cancer, and finds esophagitis that requires
560631 - taking Omeprazole twice a day. ref SDS 95 8482
560633 - ..
560634 - Discharge instructions continue...
560635 -
560636 - 10. Follow up with [ ] Primary Care Provider [ ] GI clinic
560637 -
560638 - Nothing is checked in this section, but no follow up required.
560639 -
560640 - Date/Time.....................
560642 - ..
560643 - Discharge document is not dated.
560645 - ..
560646 - Discharge instructions continue...
560647 -
560648 - 11. Nurse Signature
560650 - ..
560651 - No signature was entered.
560653 - ..
560654 - Discharge instructions continue...
560655 -
560656 - 12. Patient's Signature Date/Time
560657 -
560658 - 13. My signature indicates that I understand and have received a
560659 - copy of these instructions.
560661 - ..
560662 - This form was signed before the procedure and without post procedure
560663 - instructions and noted above reporting VA asked for signature on blank
560664 - form prior to starting work. ref SDS 0 SR8M
560666 - ..
560667 - As noted, on leaving the VA, Susan submitted an entirely blank form
560668 - without signature and name imprint, per above. ref SDS 0 PR4S
560670 - ..
560671 - Discharge instructions continue...
560672 -
560673 - 14. Imprint Patient Data Card (name address social security DOB)
560680 - ..
560681 - 15. Medical Record Nursing Documentation
560683 - ..
560684 - 16. VA Form 10-9096
560686 - ..
560687 - Note did actually get VA Form 10=9096, but the form received has
560688 - generally the same entries, and in any case was entirely blank.
560689 -
560690 -
560691 -
560692 -
560694 - ..
5607 -
5608 -
5609 - 1518
5610 -
561001 - ROI Inquired About Getting Medical Chart at VA Clinic Martinez
561002 -
561003 - On leaving the GI Clinic, asked for Release of Information (ROI)
561004 - Department.
561006 - ..
561007 - The clerk a the admitting desk said to go out the main entryway, and
561008 - turn right. There are a series of outside office trailors. ROI is
561009 - the 2nd or 3rd office.
561011 - ..
561012 - We found ROI for Sacramento VA Medical Center.
561014 - ..
561015 - Unlike at the VA in Martinez, there is no one in attendance.
561017 - ..
561018 - There are instructions on the wall to fill out forms.
561020 - ..
561021 - Walked down the hall and found a door to an office where two women
561022 - were working.
561024 - ..
561025 - Asked a woman working with a computer doing data entry of some kind,
561026 - about getting ROI files at the VA Clinic in Martinez, for work
561027 - performed at the Sacramento VA Medical Center?
561029 - ..
561030 - The lady said she does not work for ROI, and that instructions on the
561031 - all in the lobby say to fill out forms which ROI staff pickup and
561032 - process later.
561034 - ..
561035 - Explained trying to determine that the VA ROI department in Martinez
561036 - can access the computer at the Sacramento Medical Center to provide
561037 - patient records for the work today in Sacremento.
561039 - ..
561040 - The lady was very helpful. She walked from her office to another
561041 - office across the lobby and down the hall. She knocked on the door.
561042 - There was a voice that said something like "Read instructions on the
561043 - wall." The lady was persistent. She knocked again and said through
561044 - the door that clarification is needed.
561046 - ..
561047 - A young man opened the door. The lady explained the situation. The
561048 - man said that customers can get medical record files at the VA in
561049 - Martinez for work performed today at the Sacremento VA Medical Center.
561051 - ..
561052 - Thanked the man and especially the lady for excellent VA service.
561053 -
561054 -
561056 - ..
5611 -
5612 -
5613 - 1752
5614 -
561401 - Took Kathy to dinner at Chilli's...
561402 -
561403 - Chilli's
561404 - Sacremento, CA
561406 - ..
561407 - Date............................... 120322
561408 - Guests............................. 2
561409 - ..
561410 - Total..............................$28.69
561412 - ..
561413 - Tip................................ 5.00
561415 - ..
561416 - Total paid.........................$33.69
561418 - ..
561419 - For some reason the credit card was only charged $28.69; afterwards
561420 - Kathy recalled we added $5.00 for the tip, but it was not charged.
561421 -
561423 - ..
561424 - Posted expense ledger up to date...
561427 -
561428 -
561429 -
561430 -
5615 -
SUBJECTS
Default Null Subject Account for Blank Record
5703 -
570401 - ..
570402 - Medical Chart Progress Notes
570403 - Chronic Swallowing Requires Dilation Conflicts Objectives Surgery
570404 -
570405 - Follow up ref SDS 90 QF6L, ref SDS 86 QF6L.
570406 -
570407 - 1. LOCAL TITLE: EGD 60111
570408 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
570409 - DATE OF NOTE: MAR 22, 2012@11:00 ENTRY DATE: MAR 26, 2012@13:59:07
570410 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
570411 - URGENCY: STATUS: COMPLETED
570412 -
570413 - *** EGD 60111 Has ADDENDA ***
570415 - ..
570416 - 2. PATIENT NAME: WELCH, RODNEY CHARLES
570417 - DATE OF BIRTH: 03/01/1945
570419 - ..
570420 - 3. PROCEDURE:
570421 -
570422 - 1. Esophagogastroduodenoscopy.
570423 - 2. Endoscopic biopsy.
570424 - 3. TTS balloon dilation of distal esophagus.
570426 - ..
570427 - 4. ATTENDING PHYSICIAN: Randall E. Lee, M.D.
570429 - ..
570430 - 5. INDICATIONS:
570431 -
570432 - 1. Rodney Charles Welch is a 67-year-old man with a prior
570433 - history of achalasia. He underwent laparoscopic
570434 - fundoplication and myotomy at the San Francisco VA Medical
570435 - Center. Subsequently he developed acid reflux and distal
570436 - esophageal stricture that required repeated endoscopic
570437 - dilation with injection of triamcinolone. His most recent
570438 - EGD and dilation was in November 2011 at which time his
570439 - distal esophagus was dilated to 18 mm. Triamcinolone was
570440 - not injected at that time.
570442 - ..
570443 - This aligns with the report on 111115 1300. ref SDS 90 IS6L
570445 - ..
570446 - Progress Notes for 120322 continue...
570447 -
570448 - 2. Since then, the patient reduced his omeprazole from 40 mg
570449 - twice daily to 20 mg once daily because of concern the
570450 - omeprazole was causing his hypertension. He has had some
570451 - episodes of vomiting/regurgitation.
570453 - ..
570454 - 3. He is now here for reevaluation of possible further
570455 - dilation.
570457 - ..
570458 - 6. CONSENT:
570460 - ..
570461 - The risks, benefits, and alternatives to this procedure
570462 - including, but not limited to the risks of bleeding and bowel
570463 - perforation were explained to the patient. The patient
570464 - understood and provided written informed consent.
570466 - ..
570467 - 7. INTRAVENOUS MEDICATION:
570468 -
570469 - 1. Diphenhydramine 50 mg.
570470 - 2. Fentanyl 150 mcg.
570472 - ..
570473 - This reduced today from 200 mcg in prior procedure on 111115 1300.
570474 - ref SDS 90 TN6J
570475 -
570476 - [On 120925 0900 Fentanyl was increased back to 200 mcg for
570477 - the next EGD dilation procedure. ref SDS 96 625J
570479 - ..
570480 - Progress Notes for 120322 continue...
570481 -
570482 - 3. Midazolam 4 mg.
570483 -
570485 - ..
570486 - 8. PROCEDURE:
570487 -
570488 - 1. In the Sacramento VA GI Endoscopy Unit the patient was
570489 - placed in the left lateral decubitus position.
570490 -
570491 - 2. Oxygen at 2 liters per minute by nasal cannula was
570492 - administered.
570494 - ..
570495 - 3. Continuous oxymetric and hemodynamic monitoring was
570496 - initiated.
570498 - ..
570499 - 4. Intravenous sedation was administered in divided doses.
570501 - ..
570502 - 5. After a bite block was placed in the patient's mouth, an
570503 - Olympus GIF-Q180 video gastroscope was advanced under
570504 - direct vision to the esophagus.
570506 - ..
570507 - 6. Some retained saliva in the esophagus was easily irrigated
570508 - and suctioned away.
570510 - ..
570511 - 7. At 39 cm was a mild esophageal narrowing without evidence
570512 - of mass effect. This area was examined under both white
570513 - light and narrow band imaging. The endoscope passed
570514 - through this region with a mild amount of pressure and then
570515 - advanced into the descending duodenum.
570517 - ..
570518 - 8. Retroflexed views of the incisura, fundus, and cardia were
570519 - performed.
570521 - ..
570522 - 9. Random biopsies were taken from the distal antrum labeled
570523 - A, and from the proximal antrum labeled B.
570525 - ..
570526 - 10. Biopsies were also obtained at the GE junction at 39 cm
570527 - labeled C.
570529 - ..
570530 - 11. A TTS balloon dilator was then advanced across the distal
570531 - esophagus and inflated to 15 mm. The balloon did not
570532 - engage the stricture and the balloon was then inflated to
570533 - 16.5 mm. Again, the balloon did not engage the esophagus
570534 - and so the balloon was inflated to 18 mm.
570536 - ..
570537 - This is an excellent report, and appears conflicting with patient
570538 - experiencing continued problems with swallowing and vomitting, per
570539 - above. ref SDS 0 UI9H
570540 -
570541 - LESV Dilated
570542 - Date from - to
570543 - 120322 16.5 18...................... ref SDS 0 516N
570544 - 111115 16.5 18...................... ref SDS 90 IR57
570545 - 110819 15 16.5...triamcinolone.... ref SDS 87 J978
570546 - 110429 13 16.5...triamcinolone.... ref SDS 78 U23I
570547 - 110218 11 14.....triamcinolone.... ref SDS 73 AA5O
570548 - 101210 11 14...................... ref SDS 66 H347
570549 - 100827 11 15...................... ref SDS 49 JE6X
570550 - 100305 11 15...................... ref SDS 42 WR6L
570552 - ..
570553 - [On 120925 0900 LESV dilated again to 18 mm, rather than
570554 - size of healthy LESV 20 mm. ref SDS 98 XB51
570556 - ..
570557 - Progress Notes for meeting on 120322 continue...
570558 -
570559 - 12. This engaged the esophagus and a small mucosal tear was
570560 - noted. No perforation was identified.
570562 - ..
570563 - 13. Triamcinolone acetate was not injected at that time.
570565 - ..
570566 - Today, prior to procedure, patient reported case study showing
570567 - increased problems swallowing that caused increased vomitting, shown
570568 - above. ref SDS 0 UI9H
570570 - ..
570571 - On 111115 1300 doctor Impressions in Progress Notes report that adding
570572 - triamcinolone steriod injection on prior 3 procedures on 110216,
570573 - 110218 0730, ref SDS 73 A296, and on 110419, ref SDS 78 SS5N, and
570574 - again on 110819, ref SDS 87 J985, to resist contraction of LESV was
570575 - effective to avoid severe swallowing and vomitting problems,
570576 - ref SDS 90 AW6J; yet, for some reason does not present this
570577 - explanation here, nor that for some reason triamcinolone injection was
570578 - not performed on 111115. ref SDS 90 IS6L On 110419, customer reported
570579 - improved swallowing, ref SDS 78 FE3F, following injection of
570580 - triamcinolone on 110218. ref SDS 73 A296
570581 -
570582 - [On 120925 0900 Progress Notes report triamcinolone
570583 - steriod injections resumed to resist contraction of LESV
570584 - that aids swallowing. ref SDS 98 R87N
570586 - ..
570587 - Progress Notes for meeting on 120322 continue...
570588 -
570589 - 14. The previously tattooed site was again examined in the
570590 - esophageal body and no mass effect was identified.
570592 - ..
570593 - 15. The stomach was decompressed and the gastroscope removed.
570595 - ..
570596 - 9. COMPLICATIONS: None.
570598 - ..
570599 - 10. FINDINGS:
570600 -
570601 - 1. Previous area of esophagus tattoo at approximately 34-35
570602 - cm, once again without evidence of mass effect. As this
570603 - area was biopsied previously in November, this was not
570604 - biopsied again.
570606 - ..
570607 - 2. Esophageal stricture at 39 cm with some irregularity of the
570608 - Z-line noted under narrow band imaging. This was biopsied,
570609 - then balloon dilated to 18 mm.
570611 - ..
570612 - 3. Atonic esophageal body with retained saliva, but no food
570613 - contents and without friable mucosa
570615 - ..
570616 - 4. Distorted fundus consistent with known fundoplication.
570618 - ..
570619 - 5. Pale atrophic appearing distal antral gastric mucosa
570620 - without evidence of mass, ulcerations or erosions.
570622 - ..
570623 - 6. Normal pylorus.
570625 - ..
570626 - 7. Normal duodenum to D2.
570627 -
570629 - ..
570630 - 11. IMPRESSION:
570631 -
570632 - 1. Gastroesophageal reflux stricture with some mild recurrence
570633 - most likely due to the patient's self reduction of proton
570634 - pump inhibitor therapy.
570635 -
570636 - "Proton pump inhibitor therapy" refers to Omeprazole pills.
570638 - ..
570639 - On 111115 1300 doctor Impressions in Progress Notes report that adding
570640 - triamcinolone steriod injection on prior 3 procedures on 110218 0730,
570641 - ref SDS 73 A296, and on 110419, ref SDS 78 SS5N, and again on 110819,
570642 - ref SDS 87 J985, to resist contraction of LESV was effective to avoid
570643 - severe swallowing and vomitting problems, ref SDS 90 AW6J; yet, does
570644 - not present here why swallowing degraded again, after ending
570645 - triamcinolone injection on 111115, ref SDS 90 IS6L, nor why it was not
570646 - injected today, shown above, ref SDS 0 5179, in light of case study
570647 - showing that after triamcinolone injection was ended on 111115,
570648 - swallowing problems and vomitting increased, see above. ref SDS 0 UI9H
570649 -
570650 - [On 120925 0900 Progress Notes report patient taking
570651 - Omeprazole according to daily prescription, which aligns
570652 - with patient history. ref SDS 97 TA7I
570654 - ..
570655 - [On 120925 0900 doctor concludes in Impression section of
570656 - Progress Notes that gastroesophageal reflux stricture with
570657 - significant recurrence from prior examination and dilation
570658 - of March 2012 - progression of stricture may have resulted
570659 - from nonuse of triamcinolone acetate on the prior
570660 - endoscopic therapies. ref SDS 97 E558
570662 - ..
570663 - Progress Notes for meeting on 120322 continue...
570664 -
570665 - 2. Atonic esophageal body with retained esophageal saliva
570666 - consistent with known diagnosis of achalasia.
570668 - ..
570669 - 3. Probable atrophic gastritis most prominent in the
570670 - distal antrum.
570672 - ..
570673 - 12. RECOMMENDATIONS:
570674 -
570675 - 1. Increase omeprazole from current self administered dose of
570676 - 20 mg once daily to 20 mg twice daily.
570677 -
570678 - 2. The patient is to continue to remain upright after eating
570679 - for approximately 30 minutes and to continue to wash solid
570680 - food down with liquids.
570682 - ..
570683 - 3. Repeat EGD with dilation in approximately 6 months.
570685 - ..
570686 - 4. Await the biopsy results.
570688 - ..
570689 - 13. DISPOSITION:
570690 -
570691 - 1. The patient was observed in the Recovery Room and then
570692 - discharged to home with a companion.
570693 -
570694 - 2. I reviewed the endoscopic findings with the patient and his
570695 - sister prior to discharge.
570697 - ..
570698 - 14. TIME START: 1116 hours.
570700 - ..
570701 - 15. TIME END: 1135 hours.
570703 - ..
570704 - 16. D: 03/22/2012
570705 - T: 03/22/2012
570706 - Job number: 956030
570707 - MKG/CMTS
570708 - $end:
570709 - /es/ RANDALL E LEE, MD
570710 - STAFF PHYSICIAN, GASTROENTEROLOGY
570711 - Signed: 03/28/2012 10:14
570712 -
570714 - ..
570715 - Biopsy Results Negative for Actionable Findings
570716 -
570717 -
570718 - 17. 03/28/2012 ADDENDUM
570719 - STATUS: COMPLETED
570720 -
570721 - Microscopic exam/diagnosis: (Date Spec taken: Mar 22, 2012)
570722 -
570723 - A. STOMACH, DISTAL ANTRUM (BIOPSY):
570724 -
570725 - - CHRONIC GASTRITIS
570726 - - NO EVIDENCE OF HELICOBACTER PYLORI IS SEEN WITH WARTHIN-STARRY
570727 - STAIN
570729 - ..
570730 - B. STOMACH, PROXIMAL ANTRUM (BIOPSY):
570731 -
570732 - - FUNDIC MUCOSA WITH CHRONIC GASTRITIS
570733 - - NO EVIDENCE OF HELICOBACTER PYLORI IS SEEN WITH WARTHIN-STARRY
570734 - STAIN
570736 - ..
570737 - C. GASTROESOPHAGEAL JUNCTION (BIOPSY):
570738 -
570739 - - SQUAMOCOLUMNAR MUCOSA WITH REFLUX ESOPHAGITIS AND ULCERATION
570740 - - NO INTESTINAL METAPLASIA (NO BARRETT'S ESOPHAGUS)
570741 -
570742 -
570744 - ..
570745 - Medical Chart Letter to Patient
570746 -
570747 - Letter from Doctor Lee...
570748 -
570749 - 1. In Reply Refer To: Sacramento VA
570750 - Gastroenterology (111G/SAC)
570751 -
570753 - ..
570754 - 2. Date.......................... 28 March 2012
570755 -
570765 - ..
570766 - 3. You had an endoscopic examination of your esophagus, stomach,
570767 - and duodenum (EGD) at the Sacramento VA Medical Center on 22
570768 - March 2012. The biopsies showed NO cancer or infection, or
570769 - precancerous conditions. I dilated the esophagus to 18mm like
570770 - before.
570772 - ..
570773 - 4. The biopsies did confirm that you have acid reflux damage to
570774 - your lower esophagus.
570776 - ..
570777 - 5. Please take the omeprazole twice a day to protect your
570778 - esophagus from additional acid damage. I'll see you in
570779 - September for your next EGD.
570781 - ..
570782 - 6. Truly yours,
570783 -
570785 - Gastroenterologist, VA NCHCS
570786 -
570788 - STAFF PHYSICIAN, GASTROENTEROLOGY
570789 - Signed: 03/28/2012 10:19
570790 -
570791 -
570793 - ..
570794 - Medical Chart GI Procedure Note
570795 - Procedure Note GI Medical Chart
570796 - GI Procedure Note Medical Chart
570797 -
570798 -
570799 - 1. LOCAL TITLE: GI Procedure Note
570800 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
570801 - DATE OF NOTE: MAR 22, 2012@12:27 ENTRY DATE: MAR 22, 2012@12:27:11
570802 - AUTHOR: SAMSON,LARAMIE EXP COSIGNER:
570803 - URGENCY: STATUS: COMPLETED
570805 - ..
570806 - 2. Attaching GI Procedure into Vista Imaging. To see procedure
570807 - report sign into Vista Imaging Display.
570808 -
570809 - /es/ Laramie Samson, RN
570810 - Staff Nurse, GI Clinic
570811 - Signed: 03/22/2012 12:27
570812 -
570813 -
570814 -
570815 -
570816 -
570817 -
570818 -
570819 -
570820 -
570821 -
570822 -
570823 -
570824 -
570825 -
5709 -