CONTACTS
SUBJECTS
VA Achalasia Heller Myotomy Surgery Objective Improve Swallowing Req
2303 -
2303 - ..
2304 - Summary/Objective
2305 -
230501 - Follow up ref SDS 22 0000. ref SDS 20 0000.
230502 -
230503 -
230504 -
230505 -
230507 - ..
2306 -
2307 -
2308 - Progress
2309 -
230901 - Barium swallow test performed - ordered by Doctor Stewart during
230902 - meeting at VA in San Francisco on 121016 1302. ref SDS 20 E45J
230904 - ..
230905 - Doctor said today test results show no improvement compared to the
230906 - original barium swallow test on 050714 1000. ref SDS 1 WE4H, as
230907 - discussed with Doctor Lee a few months later on 051202 1430,
230908 - ref SDS 2 5B5K, and which subseqently led to Heller Myotomy surgery on
230909 - 091216 0600. ref SDS 5 KE8T Test results today further appear similar
230910 - to the CT test 2 days after Heller Myotomy surgery, performed on
230911 - 091218 0541. ref SDS 6 ER69
230913 - ..
230914 - After the test, had lunch in the cafeteria, hamburger and onion
230915 - rings.
230917 - ..
230918 - After lunch walked to the Legion of Honor museum a few blocks from
230919 - the hospital.
230921 - ..
230922 - Meeting with Doctor Stewart.
230924 - ..
230925 - Doctor Stewart reviewed the analyst report on the CT barium swallow
230926 - test performed earlier this morning, per above. ref SDS 0 4X5H
230927 - She examined the CT test imaging on the computer screen in the
230928 - examination room.
230930 - ..
230931 - The doctor called the attending physician for the barium swallow test,
230932 - and explained her interpretation of the CT imaging, and requested that
230933 - the doctor change his analysis to report that the barium swallow test
230934 - today shows improvement compared to prior study on 091218, 2 days
230935 - after Heller Myotomy surgery to resolve achalasia, ref SDS 6 ER69, and
230936 - reported a year later in the record on 100928 0706. ref SDS 9 R43F
230938 - ..
230939 - [On 130117 0900 and 7 days after EGD dilatation procedure,
230940 - barium swallow CT test shows significant improvement
230941 - compared to original condition on 050714, ref SDS 1 B94J -
230942 - follow up testing after surgery on 091218, and the test
230943 - last month on 121113, in that testing today shows there is
230944 - no big bulge and no long string-like structure preventing
230945 - content from flowing into the stomach. ref SDS 26 OH6G
230946 -
230947 -
230949 - ..
230950 - Doctor Stewart feels nothing further can be done surgically to improve
230951 - swallowing, and correct evident failure of "wrap" (formerly "flap,"
230952 - described on 091030 0810, ref SDS 3 OY69). She indicated that the
230953 - best care in this case is continuing quarterly and bi-annually
230954 - pneumatic (balloon) dilation procedures, as done the past 3 years, and
230955 - listed in the record meeting with Doctor Stewart and CJ at the VA in
230956 - San Francisco on 121016 1302. ref SDS 20 XS62
230958 - ..
230959 - Doctor Stewart initially cited the meeting 3 weeks ago, when she
230960 - indicated reflux should occur from the stomach into the esophagus and
230961 - throat, causing drowning sensation, and only when laying on the right
230962 - side, reported on 121016 1302. ref SDS 20 6O5I The doctor then
230963 - explained having reviewed the matter again after meeting on 121013.
230964 - This post meeting review determined that reflux in this case occurs
230965 - laying on the left side, because she used tissue from the left side to
230966 - construct the protective wrap inside the stomach that reduces
230967 - backflow, as originally planned in the meeting on 091030 0810.
230968 - ref SDS 3 OY64 and this changes patient anatomy to cause reflux
230969 - pattern different from normal human stomach anatomy. This explanation
230970 - today aligns with Doctor Lee's assessment in the meeting at the VA on
230971 - 120925 0900. ref SDS 17 FO4I
230973 - ..
230974 - The doctor cited several drugs that might be tried to increase the
230975 - rate clearing stomach contents after eating. She described side
230976 - effects that seem problematic.
230978 - ..
230979 - Decided not to try drug therapies at this time.
230981 - ..
230982 - Doctor Stewart will consider for discussion at the next follow up
230983 - meeting remedies to repair the failed wrap that restores original
230984 - function to accomplish objectives on preventing backflow reflux into
230985 - the esophagus, planned in the meeting on 091030 0810. ref SDS 3 OY64
230987 - ..
230988 - The doctor ordered test by ENT to investigate cause of voice disorder
230989 - which was diagnosed by CJ during the meeting at the VA on 121016 1302.
230990 - ref SDS 20 AE7K
230991 -
230992 - [On 121115 1600 Karen scheduled meeting with ENT at VA
230993 - medical Center in San Francisco on 121221 0830. ref SDS 23
230994 - 4X5H
230996 - ..
230997 - Doctor Stewart indicated that hiking and weight loss can cause reflux
230998 - into the esophagus and this might cause reflux to collect that damages
230999 - vocal chords. She asked about changes in hiking that could correlate
231000 - with increased voice disorder?
231001 -
231002 - [On 121221 0830 Doctor Poss in VA ENT Department at San
231003 - Francisco Medical Center again noticed voice disorder and
231004 - made examination for determination of causation.
231005 - ref SDS 25 WW7N
231007 - ..
231008 - After ENT test within next month, will meet with Doctor Stewart to
231009 - review findings and needs for additional care. Meeting with Doctor
231010 - Stewart was scheduled for 130115 1320. another Tuesday.
231012 - ..
231013 - Doctor Stewart explained salt causes water to accumulate that in turn
231014 - increases the work load on the heart, thus presenting a medical risk
231015 - for CAD patients. This risk is evident from high blood pressure, also
231016 - called "hypertension," and by high sodium labs. She indicated that
231017 - labs showing low sodium and low blood pressure suggest low coronary
231018 - risk.
231020 - ..
231021 - The doctor scheduled follow up meeting on 130108, to review status on
231022 - pending issues on repairing the failed wrap, and following meeting
231023 - with ENT Department in December.
231025 - ..
231026 - After the meeting today, met with Jo, the General Surgery Clinic
231027 - attendant at the front desk. She changed the meeting date with Doctor
231028 - Stewart from 130108, to the following Tuesday on 130115 0830.
231029 -
231030 - [On 121221 0700 Kathy is working on 130114; and proposed
231031 - changing the meeting with ENT to 130122 at 0800, and then
231032 - meet with Doctor Stewart in General Surgery also on 130122
231033 - after lunch at 1330. ref SDS 24 EJ5H
231035 - ..
231036 - [On 130117 0900 letter to Isagani requests facilitate
231037 - communication again with Doctor Stewart to prepare for
231038 - meeting on 130122, by reviewing results from barium swallow
231039 - test. ref SDS 26 LT4M
231041 - ..
231042 - Not clear why cannot meet with the doctor on 121218, rather than wait
231043 - until 130115.
231045 - ..
231046 - Jo said ENT will call in a few days to discuss scheduling a consult on
231047 - Doctor Stewart's referral today.
231048 -
231049 - [On 121115 1600 Karen scheduled meeting with ENT at VA
231050 - medical Center in San Francisco on 121221 0830. ref SDS 23
231051 - 4X5H
231053 - ..
231054 - [On 121221 0830 Doctor Poss in VA ENT Department at San
231055 - Francisco Medical Center again noticed voice disorder and
231056 - made examination for determination of causation.
231057 - ref SDS 25 WW7N
231058 -
231059 -
231060 -
2311 -
SUBJECTS
Default Null Subject Account for Blank Record
2403 -
240401 - ..
240402 - Medical Chart Meeting with Doctor Stewart
240403 -
240404 - Progress notes issued by VA for meeting above...
240405 -
240406 - 1. Local Title: General Surgery Clinic Consult Note (Surg/Consult)
240407 - Standard Title: Surgery Outpatient Consult
240408 - Date of Note: November 13, 2012 1407
240409 - Entry Date: November 13, 2012 1408
240410 - Author: Stewart, Lygia
240411 - Exp Cosigner:
240412 - Urgency
240413 - Status: Completed
240415 - ..
240416 - 2. Mr Welch is a 67 year old man who is s/p Heller Myotomy / Dor
240417 - funoplication in 12/2009. He was also supplemented with
240418 - esophageal dilation following this about every 4 months, and
240419 - now every 6 months. He reports that his swallowing is better
240420 - than before the surgery with the combined treatment regimen.
240421 - He is able to eat steak, any food he wants, but has to chew
240422 - well, and drink liquid with the meal. He is also on PPI. He
240423 - reports that when he lies on his left, he has reflux, but not
240424 - when he lies on his right. This makes sense since he may empty
240425 - better into the duodenum when lying on his right. He returns
240426 - today after having an UGI.
240428 - ..
240429 - 3. He also reports that he has noticed some hoarseness in the past
240430 - 3 months. The only thing he can relate to this is an increased
240431 - hiking during this time. It is not there all the time. He has
240432 - not been evaluated by ENT.
240434 - ..
240435 - 4. Patient Medical History (PMH)
240436 -
240437 - Computerized Problem List is the source for the following:
240438 -
240439 - 1. Esophageal Achalasia * (ICD-9-CM 530.0)
240440 -
240441 - 08 December 2009, Tabrizi, Ranna
240443 - ..
240444 - This refers to the meeting with Doctor Tabrizi and Doctor Stewart at
240445 - the VA in San Francisco on 091208 1300. ref SDS 4 PQ4Y
240446 -
240447 - 5. Patient Surgical History (PSH)
240448 -
240449 - 1. Date of surgery.................... 091216
240450 -
240451 - Operative Proc(s):
240453 - ..
240454 - Laparoscopic Heller Myotomy, DOR Fundoplication - LAP
240455 - Myotomy Heller
240457 - ..
240458 - 2. Date of Surgery.................... 091022
240459 -
240460 - Surgeon............................ Cambronero, Neil
240462 - ..
240463 - Operative Proc(s):
240465 - ..
240466 - CABG - CABG artery-vein two
240468 - ..
240469 - 6. Medications
240470 -
240471 - 1. Rosuvastatin CA 10 MG daily
240472 -
240473 - 2. Omeprazole 20 MG BID
240475 - ..
240476 - 7. Alergies:
240477 -
240478 - Patien has answered NKA
240480 - ..
240481 - 8. Habits
240482 -
240483 - 1. Tobacco - none
240484 - 2. ETOH
240485 - 3. IVDU
240487 - ..
240488 - 9. Parental History
240489 -
240490 - 1. Mother
240491 - 2. Father
240493 - ..
240494 - Denies any otehr knowledge of cardiac, pulmonary, liver, renal
240495 - neurological disease, DM or cancer
240497 - ..
240498 - 10. Physical Examination
240499 -
240500 - Temperature.............. 97.1 F (36.2 C) (091210 0846)
240501 - Blood Pressure........... 117 74 (121113 1307)
240502 - Heart Rate............... 91 (121113 1307)
240503 - Resperation.............. 16 (091220 0846)
240504 - O2 Saturation............ 094 (121113 1307)
240505 - Weight................... 183.3 pounds (83.3 kg) (121113 1307)
240506 - Height................... 66 in (167.6 cm) (091216 1800)
240507 - Body Mass Index BMI...... 29.6 (Overweight)
240508 - Pain..................... 0 (121113 1307)
240510 - ..
240511 - 11. Examination: Healthy man in NAD
240513 - ..
240514 - 12. Barium Swallow.......................... 121113 74220 209
240516 - ..
240517 - Reading by Attending Radiologist: Still some narrowing at the
240518 - GE junction but flow of contrast is improved compared to the
240519 - prior study.
240521 - ..
240522 - 13. Impression
240523 -
240524 - Mr Welch has improvement in his symptoms after combined
240525 - surgical and GI treatment of his achalasia. We discussed the
240526 - fact that his esophagus is not normal, so he may not be able to
240527 - achieve normal swallowing. But, it is good that his symptoms
240528 - are improved. We also discussed not eating late at night, and
240529 - avoiding high-fat meals at night. The UGI shows improvement in
240530 - his emptying. Regarding the hoarseness, this could be due to
240531 - refulx, but I also think that he might benefit from an EnT
240532 - exam. He does not have Hx of tomacco use. We will send an ENT
240533 - consult.
240534 -
240535 - [On 130117 0900 barium swallow CT test shows significant
240536 - improvement compared to original condition on 050714,
240537 - ref SDS 1 B94J - there is no big bulge and no long
240538 - string-like structure preventing content from flowing into
240539 - the stomach. ref SDS 26 OH6G
240541 - ..
240542 - RTC in 6 weeks.
240543 -
240544 - /es/ Lygia Stewart, MD 2860
240546 - ..
240547 - Chief General Surgery, Assoc Chief Surgery
240548 - Signed: 121113 1427
240550 - ..
240551 - User Class: No user class for this timestamp
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