THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com
S U M M A R Y
DIARY: April 16, 2013 11:00 AM Tuesday;
Rod Welch
VA EGD dilate LESV to 20 mm evaluate Omeprazole.
1...Summary/Objective
2...Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
3...GI Department VA Sacramento Medical Center Administration EGD Dilation
4...Denial of Service Resolved Order Omeprazole Prescription VA Refill System
5...Consent Signed EGD Dilation and Meeting Review Pending Issues
6...Consultation Pending Issues and Sign Consent for EGD Dilation
7...Denial of Service Resolved Order Omeprazole Prescription VA Refill System
8...Swallowing Vomitting Difficulties - Only 4 Events in 6 Months
9...Triamcinoloe Steriod Injection Resumed Prevent LESV Contraction
10...Meeting Doctor Lee Present Results EGD Dilation Procedure
11...Results EGD Dilation Procedure Meeting Doctor Lee Present
12...Progress Notes EGD Dilation Today
..............
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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 -