CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 18
4503 -
4503 - ..
4504 - Summary/Objective
4505 -
450501 - Follow up ref SDS B2 0000. ref SDS A9 0000.
450502 -
450503 -
450504 -
450505 -
450506 -
450508 - ..
4506 -
4507 -
4508 - Background
4509 -
450901 - On 101210 EGD procedure dilated esophageal sphincter valve from 11 to
450902 - 14 mm. EGD today dilate from 14 to 17 mm. ref SDS 66 BF6L
450904 - ..
450905 - Test today was scheduled in VA's letter dated 121107, received on
450906 - 121112 1527. ref SDS A2 K37G
450908 - ..
450909 - On 101216 1021 letter commends medical team for excellent work, and
450910 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
450912 - ..
450913 - On 110218 0730 4th EGD dilation at VA in Martinez, 110218 0730,
450914 - ref SDS 73 SR8M, and using anesthesia with Fentanyl. ref SDS 73 SR5O
450916 - ..
450917 - On 110429 0830 5th EGD dilation at VA in Martinez, 110429 1230,
450918 - ref SDS 78 NU8L, and using anesthesia with Fentanyl. ref SDS 78 SR5O
450919 - Good results dilating stricture in LESV to "ring finger," Next EDG
450920 - dilation ordered in 3 months, on 110729 0730. ref SDS 78 LJ6J
450922 - ..
450923 - On 110607 1414 visited GI Department, ref SDS 82 HC5H, and Charlene
450924 - reported a computer mistakes requires scheduling next EGD dilation on
450925 - 110819 0830. ref SDS 82 N642 Requested meeting with Doctor Lee, and
450926 - for the purpose of reviewing pending action items. ref SDS 82 4P6J,
450928 - ..
450929 - On 110819 0830 EGD and Dilation of stricture at lower esphageal
450930 - sphincter valve. ref SDS 87 K37G
450932 - ..
450933 - On 111115 1300 EGD and Dilation structure lowere esphageal sphincter
450934 - valve (LESV), after 5 months. ref SDS 90 K37G
450936 - ..
450937 - On 120322 1030 EGD and Dilation structure lowere esphageal sphincter
450938 - valve (LESV), after 5 months. ref SDS 93 K37G
450940 - ..
450941 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new
450942 - VA business unit; reported patient history. Scheduled EGD and
450943 - dilation procedure for 1300; returned and performed procedure; dilated
450944 - from 9 mm to 18 mm.
450946 - ..
450947 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found
450948 - improvement recovering from acalasia, LESV contracted only slightly
450949 - from 18 mm down to 15 mm. ref SDS A9 Q333
450950 -
450951 -
450952 -
450953 -
450955 - ..
4510 -
4511 -
4512 - Progress
451301 - ..
451302 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
451303 - GI Department VA Sacramento Medical Center Administration EGD Dilation
451304 -
451305 - Follow up ref SDS A9 NU8L, ref SDS 99 NU8L.
451306 -
451307 - Applied pre-proc requirements for NPO after midnight, from letter on
451308 - 101015 1547. ref SDS 54 4J9L Last food was at 130109 2210.
451310 - ..
451311 - Stayed at Kathy's place last night in Sacremento. This morning, She
451312 - drove us to VA Medical Center at Mather AFB.
451314 - ..
451315 - Checked into GI Department at the customer counter.
451316 -
451317 - 800-382-8387
451318 -
451319 - 916 843 7000
451320 -
451321 -
451323 - ..
451324 - Submitted Kathy's cell phone for designated driver.
451328 - ..
451329 - Kathy signed the discharge form affirming she will be designated
451330 - driver, and responsible to facilitate no driving for 24 hours.
451332 - ..
451333 - Nurse at customer counter asked questions on patient history to verify
451334 - ready for procedure, e.g., no allergies, and NPO after midnight to
451335 - avoid conflicts with anesthesia; no health problems, e.g., no
451336 - diabetes, alcohol, cigarettes.
451338 - ..
451339 - Waited in lobby for 5 minutes. Then did laps around the building
451340 - until called OA 1040.
451341 -
451343 - ..
4514 -
4515 -
4516 - 0913
4517 -
451701 - Denial of Service Resolved Order Omeprazole Prescription VA Refill System
451702 -
451703 - Follow up ref SDS A9 RG9K.
451704 -
451705 - There was initial preparation for the procedure dressing down, IV
451706 - setup and administration with patient history, similar to work on
451707 - 120925 0900. ref SDS 99 UN6K
451708 -
451709 -
451711 - ..
451712 - Consent Signed EGD Dilation and Meeting Review Pending Issues
451713 - Consultation Pending Issues and Sign Consent for EGD Dilation
451714 - Denial of Service Resolved Order Omeprazole Prescription VA Refill System
451715 -
451716 - Follow up ref SDS 99 RG9K, ref SDS 93 SR4G.
451717 -
451718 - When Doctor Lee arrived, explained denial of service ordering refills
451719 - for Omeprazole on 130406 1708. ref SDS B3 5N3O
451721 - ..
451722 - Doctor Lee will order Omeprazole refill to resolve the problem.
451724 - ..
451725 - He indicated that Doctor Sandhu in Primary Care placed a hold for some
451726 - reason on 3 pending refills. This explains denial of service reported
451727 - on 130406 1708. ref SDS B3 MJ7H
451729 - ..
451730 - Denial of access to VA Internet prescription system is somewhat
451731 - similar to mix up that delayed getting Omeprazole refill reported last
451732 - year on 120927 1214. ref SDS A0 YK6F
451733 -
451734 - [On 140715 1614 another delay ordering refills for
451735 - Omeprazole this time caused by denial of service to VA
451736 - automatic scheduling that does not align with doctor's
451737 - prescription. ref SDS B9 HX5O
451739 - ..
451740 - Today, Doctor Lee cancelled the prior prescription that denied access
451741 - to refills. He ordered a new prescription with 3 new refills.
451742 -
451743 - [On 130419 0638 VA Internet medication prescription report
451744 - shows Omeprazole ordered 130417 and there are 3 refills
451745 - available. ref SDS B5 MJ7M
451747 - ..
451748 - [On 130423 1140 received refill for Omeprazole. ref SDS B6
451749 - 5N3O
451751 - ..
451752 - Reviewed results CT test on 130117 0900, ref SDS B0 HR98, showing
451753 - significant improvement reducing swelling. ref SDS B0 OH6G
451755 - ..
451756 - Reviewed analysis Doctor Stewart finding that CT test on 130117,
451757 - ordered by Doctor Lee, shows favorable response to treatment resolving
451758 - achalasia, reported on 130122 1330. ref SDS B1 03H6
451759 -
451760 -
451762 - ..
451763 - Swallowing Vomitting Difficulties - Only 4 Events in 6 Months
451764 - Triamcinoloe Steriod Injection Resumed Prevent LESV Contraction
451765 -
451766 - Follow up ref SDS 99 TZ4M, ref SDS 93 UI9H.
451767 -
451768 - Doctor Lee asked about swallowing and vomitting since the prior
451769 - meeting when he resumed triamcinolone steriod injections to resist
451770 - contractions of LESV, so that effects of dilation on aiding swallowing
451771 - last longer?
451773 - ..
451774 - Reported swallowing has been good, and so vomitting mostly mild during
451775 - past 6 months, since prior procedure on 120925 0900, ref SDS 99 TZ4M,
451776 - when Doctor Lee resumed triamcinolone steriod injections, shown also
451777 - in Progress Notes on 120925. ref SDS 99 R87N
451779 - ..
451780 - Explained Doctor Lee can check daily progress on vomitting since prior
451781 - procedure on 120925, by examining the record of patient vitals,
451782 - medication, diet and exercise in case study on the Internet dated
451783 - 120101 0900, ref SDS 92 UX4H, and showing...
451784 -
451785 - 20%.................... 120928
451786 - 4%.................... 121107
451787 - 5%.................... 121128
451788 - 100%..not achalasia..... 130205 .... norovirus infection
451789 - 5%.................... 130314
451791 - ..
451792 - Four (4) mild events over 6 months, due to achalasia is remarkable
451793 - improvement compared to 16 events in prior study without triamcinolone
451794 - steriod injections, shown on 120925 0900, ref SDS 99 GD8J; and
451795 - compared to 32 events in the next prior study on 120322 1030.
451796 - ref SDS 93 UI9H
451797 -
451798 -
451800 - ..
451801 - Meeting Doctor Lee Present Results EGD Dilation Procedure
451802 - Results EGD Dilation Procedure Meeting Doctor Lee Present
451803 -
451804 - Follow up ref SDS A9 134H, ref SDS 93 SR6K.
451805 -
451806 - An hour or so after the procedure, met with Doctor Lee in the recovery
451807 - room.
451809 - ..
451810 - Doctor Lee reported good news...
451812 - ..
451813 - LESV remained at 18 mm past 4 months, so next EGD dilation in 6
451814 - months, October 131001.
451816 - ..
451817 - LESV did not contract over past 4 months by any measurable amount.
451818 - The pneumatic dilation balloon did not engage esophageal tissue until
451819 - reaching 18 mm, which is the size dilated during the prior meeting on
451820 - 130110 0900. ref SDS A9 134H
451822 - ..
451823 - Thanked Doctor Lee for outstanding care.
451825 - ..
451826 - Attributed success reported previously on 130117, and noted that very
451827 - favorable findings today reflect Doctor Lee's persistance ordering EGD
451828 - dilation procedures the past 3 years, despite initial poor results,
451829 - and the doctor's ingenuity adding triamcinolone steriod injections to
451830 - resist contraction of LESV that aids swallowing to prevent swelling of
451831 - esophagus and vomitting, beginning on 110218 0730. ref SDS 73 SR4G
451832 -
451833 - LESV Dilated
451834 - Date from - to
451835 - 130416 18 18.....triamcinolone.... ref SDS 0 Q333
451836 - 130110 15 18.....triamcinolone.... ref SDS A9 Q333
451837 - 120925 15 18.....triamcinolone.... ref SDS 99 XB51
451838 - 120322 16.5 18...................... ref SDS 93 516N
451839 - 111115 16.5 18...................... ref SDS 90 IR57
451840 - 110819 15 16.5...triamcinolone.... ref SDS 87 J978
451841 - 110429 13 16.5...triamcinolone.... ref SDS 78 U23I
451842 - 110218 11 14.....triamcinolone.... ref SDS 73 AA5O
451843 - 101210 11 14...................... ref SDS 66 H347
451844 - 100827 11 15...................... ref SDS 49 JE6X
451845 - 100305 11 15...................... ref SDS 42 WR6L
451847 - ..
451848 - This record was presented in case study during the meeting with Doctor
451849 - Stewart at San Francisco VA Medical Center on 121016 1302. ref SDS A1
451850 - XS62
451852 - ..
451853 - Today, Doctor Lee explained significant improvement swallowing through
451854 - progress resolving acalasia was a team effort. He advised that Heller
451855 - Myotomy surgery, which Doctor Stewart performed on 091216 0600,
451856 - ref SDS 31 KE9U, combined with EGD protocols beginning 3 months later
451857 - on 100305 1000, ref SDS 42 E18F, and then a year later enhanced with
451858 - triamcinolone steriod injections on 110218 0730, ref SDS 73 SR4G, then
451859 - paused after 3 cycles on 111115 1300, ref SDS 90 IS6L, but resumed
451860 - again after 2 more cycles on 120925 0900, ref SDS 99 8S4I, and
451861 - continued for the prior cycle on 130110 0900. ref SDS A9 Q34P have
451862 - finally yielded dramatic results with consistent injections of
451863 - triamcinolone steriods.
451865 - ..
451866 - Doctor Lee advised that he applied triamcinolone steriod again today
451867 - to maintain improved swallowing, since this has been effective.
451868 - Progress Notes report pausing triamcinolone steriod for the EGD
451869 - dilation procedure on 111115 1300, ref SDS 90 IS6L, and was resumed 2
451870 - cycles later, shown by Progress Notes reporting this protocol is
451871 - effective, on 120925 0900. ref SDS 99 E558
451872 -
451873 - [...below on 130416 1100 Progress Note report triamcinolone
451874 - steriod injected into LESV. ref SDS 0 F38G
451876 - ..
451877 - Doctor Lee prescribed continuing Omeprazole twice a day for next
451878 - month, then reducing medication to once a day.
451880 - ..
451881 - Hopefully, this will enable reducing Omeprazole to reduce side
451882 - effects.
451883 -
451884 - [...below on 130416 1100 Doctor Lee filed addendum to
451885 - Progress Notes prescribing continuing prescription taking 2
451886 - pills of Omeprazole for only 1 month, then reducing to 1
451887 - pill per day for next 5 months until next procedure.
451888 - ref SDS 0 ZY91
451889 -
451890 -
451891 -
451892 -
451893 -
451894 -
4519 -
SUBJECTS
Default Null Subject Account for Blank Record
4603 -
460401 - ..
460402 - Progress Notes EGD Dilation Today
460403 -
460404 - Received Progress Notes...
460405 -
460406 - F:\05\00003\SM\CC\AGMJ\20130416122245\welch_050713.pdf
460407 -
460408 - 1. Progress Notes Printed On May 07, 2013
460409 - LOCAL TITLE: EGD 60111
460410 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
460411 - DATE OF NOTE: APR 16, 2013@12:22
460412 - ENTRY DATE: APR 16, 2013@12:22:45
460414 - ..
460415 - 2. AUTHOR: PARIKH,DHAVAN EXP COSIGNER: LEE,RANDALL E
460416 - URGENCY: STATUS: COMPLETED
460417 -
460418 - 3. *** EGD 60111 Has ADDENDA ***
460420 - ..
460421 - 4. ESOPHAGOGASTRODUODENOSCOPY REPORT APR 16, 2013
460423 - ..
460424 - 5. PATIENT NAME; WELCH,RODNEY CHARLES 561-72-0144
460426 - ..
460427 - 6. PREOPERATIVE DIAGNOSIS:
460428 -
460429 - 1. Achalasia
460430 - 2. Peptic stricture
460432 - ..
460433 - 7. POSTOPERATIVE DIAGNOSIS:
460434 -
460435 - 1. Achalasia
460436 - 2. Peptic stricture s/p TTS balloon dilation
460438 - ..
460439 - 8. SUBPROCEDURE:
460440 -
460441 - 1. TTS balloon dilation of distal esophagus.
460442 - 2. Endoscopic injection of triamcinolone.
460444 - ..
460445 - 9. INDICATIONS:
460446 -
460449 -
460450 - 1. 67-year-old man with a history of achalasia. He underwent
460451 - laparoscopic myotomy and fundoplication at San Francisco VA
460452 - Medical Center.
460453 -
460454 - 2. He subsequently developed acid reflux and a distal
460455 - esophageal stricture that has required repeat endoscopic
460456 - dilations.
460458 - ..
460459 - 3. His last EGD and dilation was on 01/10/2013, at which time,
460460 - his stricture was dilated from 15 to 18 mm and 3 mL of
460461 - triamcinolone acetate with a concentration of 40 mg/mL was
460462 - injected into the distal esophageal stricture.
460464 - ..
460465 - 4. Patient now returns for repeat dilation. Generally sx
460466 - (symptom) free, but has noted a slight increase in
460467 - dysphagia since his last dilation. Compliant with Prilosec
460468 - 20 mg bid.
460470 - ..
460471 - 10. PHYSICAL EXAMINATION:
460473 - ..
460474 - 11. Vitals - most recent BMI: 31.2
460476 - ..
460477 - 12. Height: 66 in [167.6 cm] (04/16/2013 10:08)
460478 - Weight: 193 lb [87.7 kg] (04/16/2013 10:08)
460479 - Temp: 97.4 F [36.3 C] (04/16/2013 10:08)
460480 - Pulse: 61 (04/16/2013 10:08)
460481 - Resp: 16 (04/16/2013 10:08)
460482 - BP: 132/78 (04/16/2013 10:08)
460484 - ..
460485 - 13. GENERAL: awake, alert and cooperative in no acute distress.
460486 - HEART: RRR
460487 - LUNGS: CTAB
460488 - ABD: BS normal, soft, non-tender.
460489 - EXT: No edema.
460490 -
460492 - ..
460493 - 14. HEALTH STATUS: ASA class 2.
460495 - ..
460496 - 15. CONSENT: The procedure was discussed with the patient with the
460497 - benefits and risks, including but not limited to bleeding,
460498 - infection, pain, aspiration, perforation and reaction to
460499 - medications. Questions were answered. The patient was aware
460500 - of the risks and gave written informed consent.
460502 - ..
460503 - 16. ENDOSCOPIST: Dr Parikh
460505 - ..
460506 - 17. ATTENDING: Dr Lee
460508 - ..
460509 - 18. MEDICATIONS: Fentanyl 250 mcg iv, Versed 5 mg iv, Benadryl 50
460510 - mg iv
460512 - ..
460513 - 19. TIME IN: 1151
460514 - TIME OUT: 1218
460516 - ..
460517 - 20. DESCRIPTION OF PROCEDURE:
460518 -
460519 - 1. Timeout was performed prior to procedure with name, site,
460520 - and procedure confirmed. The procedure was performed in
460521 - the main endoscopy unit at VA Mather Hospital on an
460522 - outpatient basis by Drs Lee and Parikh.
460524 - ..
460525 - 2. Incremental doses of fentanyl, versed, and Benadryl were
460526 - administered for moderate conscious sedation.
460528 - ..
460529 - 3. Viscous lidocaine for pharyngeal anesthesia was used and a
460530 - bite block was inserted in the mouth.
460532 - ..
460533 - 4. The patient was placed in the left lateral decubitus
460534 - position.
460536 - ..
460537 - 5. Vital signs were monitored throughout.
460539 - ..
460540 - 6. The Olympus GIF-H180 diagnostic endoscope was directly
460541 - inserted into the mouth and the esophagus was intubated
460542 - under direct visualization.
460544 - ..
460545 - 7. Retained saliva was observed coating the esophageal mucosa
460546 - and this was easily irrigated and suctioned to examine the
460547 - esophageal mucosa.
460549 - ..
460550 - 8. The endoscope was carefully advanced to 40 cm, the site of
460551 - the known stricture. The endoscope was easily passed
460552 - through and into the stomach without any resistance.
460554 - ..
460555 - 9. The endoscope was then advanced into the stomach and to the
460556 - proximal and descending duodenum.
460558 - ..
460559 - The endoscope was then slowly withdrawn with close
460560 - examination of the mucosa. In the stomach, retroflex view
460561 - was obtained. The endoscope was then straightened. The
460562 - scope was withdrawn to the esophagus.
460564 - ..
460565 - 10. At that point a TTS balloon dilator was advanced across the
460566 - distal esophagus and inflated to 15 mm. The balloon did
460567 - not engage the esophagus at that size, and so the balloon
460568 - was further inflated sequentially to 16.5 then 18 mm. The
460569 - balloon was noted to engage the esophageal mucosa at 18 mm,
460570 - but no tearing was visualized through the balloon.
460571 -
460572 - LESV Dilated
460573 - Date from - to
460574 - 130416 18 18.....triamcinolone.... ref SDS 0 Y850
460575 - 130110 15 18.....triamcinolone.... ref SDS A9 Q333
460576 - 120925 15 18.....triamcinolone.... ref SDS 99 XB51
460577 - 120322 16.5 18...................... ref SDS 93 516N
460578 - 111115 16.5 18...................... ref SDS 90 IR57
460579 - 110819 15 16.5...triamcinolone.... ref SDS 87 J978
460580 - 110429 13 16.5...triamcinolone.... ref SDS 78 U23I
460581 - 110218 11 14.....triamcinolone.... ref SDS 73 AA5O
460582 - 101210 11 14...................... ref SDS 66 H347
460583 - 100827 11 15...................... ref SDS 49 JE6X
460584 - 100305 11 15...................... ref SDS 42 WR6L
460586 - ..
460587 - [On 131115 0700 LESV dilated again from 16.5 to 18 mm
460588 - indicating minimal contraction with triamcinolone steriod
460589 - injections. ref SDS B8 F46N
460591 - ..
460592 - 11. The balloon was then deflated and removed, and two small
460593 - areas of slight mucosal tearing was appreciated.
460595 - ..
460596 - 12. Approximately 2 mL of triamcinolone acetate at a
460597 - concentration of 40 mg/mL were injected into the areas of
460598 - slight mucosal tearing.
460600 - ..
460601 - Aligns with discussion after the procedure with Doctor Lee, above.
460602 - ref SDS 0 I167
460604 - ..
460605 - This continues protocol combining triacinolone steriod with Omeprazole
460606 - and dilation which has yielded exceptional results, reported today,
460607 - above, ref SDS 0 MT6F, and discussed with the doctor after the
460608 - dilation procedure, also above. ref SDS 0 IN5N Favorable response to
460609 - treatment combining triamcinolone steriod with Omeprazole and
460610 - dilation were previously cited in Progress notes for meetings on...
460611 -
460612 - 130110...................... ref SDS A9 Q374
460613 - 120925...................... ref SDS 99 E558
460614 - 111115...................... ref SDS 90 AW6J
460615 - 110218...................... ref SDS 73 SR4G
460617 - ..
460618 - [On 131115 0700 continued protocol injecting triamcinolone
460619 - steriod into LESV to resist contraction that aids
460620 - swallowing and avoid vomitting. ref SDS B7 QS6F
460622 - ..
460623 - Progress Notes procedure on 130416 continue...
460624 -
460625 - 13. The stomach was then decompressed and the endoscope
460626 - withdrawn from the esophagus and oropharynx.
460628 - ..
460629 - 14. The patient tolerated the procedure well and there were no
460630 - immediate complications. Dr Lee was present for the entire
460631 - viewing portion of the procedure.
460633 - ..
460634 - 21. FINDINGS:
460635 -
460636 - 1. ESOPHAGUS - proximally dilated and atonic appearing with
460637 - area of stricture again identified at 40 cm.
460639 - ..
460640 - 2. GE junction - at 40 cm
460642 - ..
460643 - 3. STOMACH - normal
460645 - ..
460646 - 4. DUODENUM - normal to D2
460648 - ..
460649 - 5. RETROFLEX - anatomy c/w prior fundoplication
460651 - ..
460652 - 22. IMPRESSION:
460653 -
460654 - 1. Atonic and proximally dilated esophagus with area of
460655 - stricture at 40 cm, easily traversed by endoscope without
460656 - resistance.
460658 - ..
460659 - 2. Status post attempted dilation of previous stricture at
460660 - 40 cm with very slight augmentation in esophageal diameter
460661 - as noted with two small mucosal tears, s/p 2 mL
460662 - triamcinolone (40 mg/mL) injection 3.
460664 - ..
460665 - 3. Anatomy consistent with previous fundoplication
460667 - ..
460668 - 23. RECOMMENDATIONS:
460669 -
460670 - 1. Continue Omeprazole 20 mg twice daily.
460671 -
460672 - 2. Chew food carefully.
460673 -
460674 - 3. GERD-related lifestyle modifications
460676 - ..
460677 - 4. Repeat EGD and dilation in approximately 6 months, or when
460678 - sx return
460679 -
460680 -
460681 - 24. /es/ Dhavan Parikh MD
460682 - Gastroenterology Fellow, PGY-5 & ED Attending
460683 - Signed: 04/16/2013 13:10
460684 -
460685 -
460686 - 25. /es/ RANDALL E LEE, MD
460687 - STAFF PHYSICIAN, GASTROENTEROLOGY
460688 - Cosigned: 04/16/2013 13:31
460689 -
460690 -
460691 - 26. 04/16/2013 ADDENDUM STATUS: COMPLETED
460692 - Gastroenterology Attending
460694 - ..
460695 - 27. EGD, TTS dilation, triamcinolone injection performed with Dr
460696 - Parikh as documented above.
460698 - ..
460699 - 28. GERD stricture is essentially unchanged from last examination
460700 - with persistence of lumen diameter at 18mm.
460702 - ..
460703 - 29. I concur with the above documentation with the following
460704 - changes:
460706 - ..
460707 - 30. I asked Mr Welch to continue with omeprazole 20mg twice daily
460708 - x 1 month, then reduce to 20mg once every evening just before
460709 - dinner. This is in accordance with his request. Will
460710 - recommend continued twice daily dosing if lumen is
460711 - significantly reduced at next EGD in October 2013.
460713 - ..
460714 - This aligns with objectives for reducing reliance on medication,
460715 - discussed with the doctor based on good news of significant recovery
460716 - from achalasia, per above. ref SDS 0 CO5N,
460717 -
460718 -
460719 - 31. /es/ RANDALL E LEE, MD
460720 - STAFF PHYSICIAN, GASTROENTEROLOGY
460721 - Signed: 04/16/2013 13:40
460722 -
460723 -
460724 -
460725 -
460726 -
460727 -
460728 -
460729 -
460730 -
460731 -
460732 -
460733 -
4608 -