CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 16.
5103 -
5103 - ..
5104 - Summary/Objective
5105 -
510501 - Follow up ref SDS B4 0000. ref SDS B2 0000.
510502 -
510503 -
510504 - [On 131121 1604 ordered refill of Omeprazole to aid
510505 - digestion. There is 1 refill remaining. ref SDS B8 YS4O
510507 - ..
510508 - [On 131205 1443 received order for Omeprazole prescription
510509 - placed on 131121. ref SDS B9 5N3O
510511 - ..
510512 - [On 140318 1043 received letter cancelling meeting
510513 - scheduled for EGD/Dilation procedure on 140425 1000,
510514 - ref SDS C0 935L; a second letter scheduled prodedure on
510515 - 140509 0900. ref SDS C0 5D7H
510516 -
510517 -
510518 -
510519 -
510521 - ..
5106 -
5107 -
5108 - Background
5109 -
510901 - On 101210 EGD procedure dilated esophageal sphincter valve from 11 to
510902 - 14 mm. EGD today dilate from 14 to 17 mm. ref SDS 66 BF6L
510904 - ..
510905 - Test today was scheduled in VA's letter dated 121107, received on
510906 - 121112 1527. ref SDS A2 K37G
510908 - ..
510909 - On 101216 1021 letter commends medical team for excellent work, and
510910 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
510912 - ..
510913 - On 110218 0730 4th EGD dilation at VA in Martinez, 110218 0730,
510914 - ref SDS 73 SR8M, and using anesthesia with Fentanyl. ref SDS 73 SR5O
510916 - ..
510917 - On 110429 0830 5th EGD dilation at VA in Martinez, 110429 1230,
510918 - ref SDS 78 NU8L, and using anesthesia with Fentanyl. ref SDS 78 SR5O
510919 - Good results dilating stricture in LESV to "ring finger," Next EDG
510920 - dilation ordered in 3 months, on 110729 0730. ref SDS 78 LJ6J
510922 - ..
510923 - On 110607 1414 visited GI Department, ref SDS 82 HC5H, and Charlene
510924 - reported a computer mistakes requires scheduling next EGD dilation on
510925 - 110819 0830. ref SDS 82 N642 Requested meeting with Doctor Lee, and
510926 - for the purpose of reviewing pending action items. ref SDS 82 4P6J,
510928 - ..
510929 - 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter
510930 - valve. ref SDS 87 K37G
510931 -
510932 - 111115 1300 EGD and Dilation structure lowere esphageal sphincter
510933 - valve (LESV), after 5 months. ref SDS 90 K37G
510934 -
510935 - 120322 1030 EGD and Dilation structure lowere esphageal sphincter
510936 - valve (LESV), after 5 months. ref SDS 92 K37G
510937 -
510938 - 120925 0900 meeting Doctor Lee reported schedule mistake using new VA
510939 - business unit; reported patient history. Scheduled EGD and dilation
510940 - procedure for 1300; returned and performed procedure; dilated from 9
510941 - mm to 18 mm.
510943 - ..
510944 - 130110 0900 meeting Doctor Lee EGD procedure found improvement
510945 - recovering from acalasia, LESV contracted only slightly from 18 mm
510946 - down to 15 mm. ref SDS A9 134H
510948 - ..
510949 - 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV
510950 - remained at 18 MM, ref SDS B4 6P6G, same as dialated 4 months earlier
510951 - on 130110 0900. ref SDS A9 134H Doctor Lee injected steriod again to
510952 - maintain swallowing. ref SDS B4 I167 Prescribed reducing Omeprazole
510953 - to 1 pill per day. ref SDS B4 R74M Scheduled next EDG dilation in 6
510954 - months, instead of 3. ref SDS B4 6P6G
510955 -
510956 -
510957 -
510958 -
510959 -
510961 - ..
5110 -
5111 -
5112 - Progress
511301 - ..
511302 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
511303 - GI Department VA Sacramento Medical Center Administration EGD Dilation
511304 -
511305 - Follow up ref SDS B4 NU8L, ref SDS B2 NU8L.
511306 -
511307 - Applied pre-proc requirements for NPO after midnight, from letter on
511308 - 101015 1547. ref SDS 54 4J9L Last food was at 131114 1722.
511310 - ..
511311 - Stayed at Kathy's place last night in Sacremento. This morning, She
511312 - drove us to VA Medical Center at Mather AFB.
511314 - ..
511315 - Checked into GI Department at the customer counter.
511316 -
511317 - 800-382-8387
511318 -
511319 - 916 843 7000
511320 -
511321 -
511323 - ..
511324 - Submitted Kathy's cell phone for designated driver.
511328 - ..
511329 - Kathy signed the discharge form affirming she will be designated
511330 - driver, and responsible to facilitate no driving for 24 hours.
511332 - ..
511333 - Nurse at customer counter asked questions on patient history to verify
511334 - ready for procedure, e.g., no allergies, and NPO after midnight to
511335 - avoid conflicts with anesthesia; no health problems, e.g., no
511336 - diabetes, alcohol, cigarettes.
511338 - ..
511339 - Waited in lobby for 5 minutes. Then did laps around the building
511340 - until called OA 1040.
511341 -
511343 - ..
5114 -
5115 -
5116 - 0748
5117 -
511701 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
511702 -
511703 - Follow up ref SDS B4 ZG3F.
511704 -
511705 - There was initial preparation for the procedure dressing down, IV
511706 - setup and administration with patient history, similar to work on
511707 - 120925 0900. ref SDS 99 UN6K
511708 -
511709 -
511710 -
511712 - ..
511713 - Consent Signed EGD Dilation and Meeting Review Pending Issues
511714 - Consultation Pending Issues and Sign Consent for EGD Dilation
511715 -
511716 - Follow up ref SDS B4 RG9K, ref SDS 99 RG9K.
511717 -
511718 - Doctor Lee came into the surgery preparation room smiling and
511719 - immediately shook hands on mutually having hiked Half Dome, saying he
511720 - did Half Dome about 20 years ago.
511722 - ..
511723 - The doctor related seeing Doctor Egan's Progress Notes for meeting on
511724 - 131017, which reporting Half Dome Hike was challenging for the
511725 - patient, but successful. ref SDS B7 V24N
511727 - ..
511728 - Doctors preparing for meetings by reading up on the record of recent
511729 - related work shows good progress toward doctor/patient partnership
511730 - that leverages talents and experience essential for effective,
511731 - comprehensive health care, discussed previously on 120925 0900.
511732 - ref SDS 99 UI3F
511734 - ..
511735 - Doctor Lee mentioned that he wants to hike Half Dome again with his 2
511736 - oldest children They enjoy hiking now in their early teens, and are
511737 - growing fast. He expects that within a year or so they will try Half
511738 - Dome together.
511739 -
511740 - [On 140509 0900 at 1040 Doctor Lee requested pictures of
511741 - Half Dome hike last year, ref SDS C1 ZZ6J, and explains to
511742 - nursing staff how he saved patients life 5 years earlier
511743 - making referral that led to timely heart surgery,
511744 - ref SDS C1 0N6I; later in the OR arranged for Doctor Lee to
511745 - see pictures hiking Half Dome in Yosemite Valley, and prior
511746 - to commencement of GI dilation procedure. ref SDS C1 LX7L
511748 - ..
511749 - Advised Doctor Lee there is no need to order Omeprazole refill,
511750 - because this was done on 130416 1100. ref SDS B4 RG9K
511752 - ..
511753 - On 130419 0638 VA Internet medication prescription report shows
511754 - Omeprazole ordered 130417 and there are 2 refills available.
511755 - ref SDS B5 MJ7M On 130423 1140 received refill for Omeprazole.
511756 - ref SDS B6 5N3O
511757 -
511758 -
511759 -
511761 - ..
511762 - Swallowing Vomitting Difficulties Decreased with Triamcinolone Injections
511763 -
511764 - Follow up ref SDS B4 QW7L, ref SDS A9 SE7K.
511765 -
511766 - Doctor Lee asked about swallowing over the prior 6 months, since the
511767 - prior EDG dilation on 130416 1100. ref SDS B4 QW7L
511769 - ..
511770 - Advised swallowing remains good since triamciolone injections resumed
511771 - on 120925 0900. ref SDS 99 TZ4M
511773 - ..
511774 - In the past month there has begun to be slight build up in esohpagus
511775 - (throat) a few times when eating, and which has caused slight
511776 - vomitting. This remains significantly improved compared to prior
511777 - severe swallowing and vomitting problems reported on 120925 0900,
511778 - ref SDS 99 TZ4M, and previously on 120322 1030. ref SDS 92 UI9H
511779 -
511780 -
511781 -
511782 -
511784 - ..
5118 -
5119 -
5120 - 1000
5121 -
512101 - Dilated 18 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee
512102 - Meeting Doctor Lee Present Results EGD Dilation Procedure
512103 - Results EGD Dilation Procedure Meeting Doctor Lee Present
512104 -
512105 - Follow up ref SDS B4 5R4N. ref SDS 99 SR6K.
512106 -
512107 - An hour or so after the procedure, met with Doctor Lee in the recovery
512108 - room.
512110 - ..
512111 - Doctor Lee reported good news...
512113 - ..
512114 - LESV contracted to only 16.5 mm past 6 months. Dilation was performed
512115 - back to 18 mm. Next EGD dilation was continued for 6 months, April
512116 - 140501.
512117 -
512118 - [...below on 131115 0700 medical chart Progress Notes may
512119 - indicate LESV contracted to 16.5 mm and was dilated to 18
512120 - mm. ref SDS 0 RZ45
512121 -
512122 - LESV Dilated
512123 - Date from - to
512124 - 131115 16.5 18.....triamcinolone.... ref SDS 0 RZ45
512125 - 130416 18 18.....triamcinolone.... ref SDS B4 Y850
512126 - 130110 15 18.....triamcinolone.... ref SDS A9 Q333
512127 - 120925 15 18.....triamcinolone.... ref SDS 99 XB51
512128 - 120322 16.5 18...................... ref SDS 92 516N
512129 - 111115 16.5 18...................... ref SDS 90 IR57
512130 - 110819 15 16.5...triamcinolone.... ref SDS 87 J978
512131 - 110429 13 16.5...triamcinolone.... ref SDS 78 U23I
512132 - 110218 11 14.....triamcinolone.... ref SDS 73 AA5O
512133 - 101210 11 14...................... ref SDS 66 H347
512134 - 100827 11 15...................... ref SDS 49 JE6X
512135 - 100305 11 15...................... ref SDS 42 WR6L
512136 - ..
512137 - Doctor Lee advised that he applied triamcinolone steriod again today
512138 - to maintain improved swallowing, since this has been effective.
512139 -
512140 - [...below on 131115 0700 medical chart Progress Notes
512141 - report injecting trimacinolone steriod. ref SDS 0 V35G
512143 - ..
512144 - Doctor Lee prescribed continuing Omeprazole once a day.
512146 - ..
512147 - Kathy understood the doctor ordered the same prescription of starting
512148 - with 2 pills a day, for a month, then reducing to 1 pill per day, as
512149 - prescribed previouly on 130416 1100. ref SDS B4 R74M
512150 -
512151 - [...below on 131115 0700 medical chart Progress Notes
512152 - report doctor ordered taking 2 pills for a month, then
512153 - reducing back to 1 pill per day. ref SDS 0 ZY5K
512155 - ..
512156 - Explained there are 2 refills remaining on the current prescription,
512157 - reported on 130419 0638. ref SDS B5 MJ7M This is sufficient to last
512158 - another 6 months, so there is no need for Doctor Lee to file another
512159 - order.
512160 -
512161 - [On 131121 1604 ordered refill of Omeprazole to aid
512162 - digestion. There is 1 refill remaining. ref SDS B8 YS4O
512164 - ..
512165 - [On 131205 1443 received order for Omeprazole prescription
512166 - placed on 131121. ref SDS B9 5N3O
512168 - ..
512169 - Kathy further recalled Doctor Lee saying he observed during EGD
512170 - procedure some new scar tissue around the LESV stricture caused by
512171 - acid reflux.
512173 - ..
512174 - Doctor Lee advised that he took 3 or 4 biopsies during the procedure.
512175 -
512176 - [...below on 131115 0700 medical chart Progress Notes
512177 - findings 2,3,5 indicate where biopsies taken to evaluate
512178 - tissue condition caused by achalasia. ref SDS 0 UP7F
512180 - ..
512181 - Results will be reported in the medical chart with Progress Notes,
512182 - probably available next week OA 131120.
512183 -
512184 -
512185 -
512186 -
5122 -
SUBJECTS
Medical Chart Progress Notes VA EGD Procedure Stricture Lower Esopha
6303 -
630401 - ..
630402 - Progress Notes EGD Dilation Today
630403 -
630404 - Follow up ref SDS B4 CY7I.
630405 -
630406 - Received Progress Notes...
630407 -
630408 - F:\05\00003\SM\CC\AGMJ\20131115-080024\Welch_11-22-13.pdf
630410 - ..
630411 - 1. Progress Notes Printed On 22 November 2013
630412 - LOCAL TITLE: EGD 60111
630413 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
630414 - DATE OF NOTE: NOV 15, 2013@08:00
630415 - ENTRY DATE: NOV 15, 2013@14:03:24
630417 - ..
630418 - 2. AUTHOR: LEE,RANDALL E
630419 - URGENCY: STATUS: COMPLETED
630420 -
630421 - 3. *** EGD 60111 Has ADDENDA ***
630422 -
630423 -
630428 - ..
630429 - 4. NAME OF PROCEDURES:
630430 -
630431 - 1. ESOPHAGOGASTRODUODENOSCOPY
630432 - 2. Endoscopic biopsy
630433 - 3. TTS balloon dilation of his esophagus.
630434 - 4. Endoscopic injection of triamcinolone.
630436 - ..
630437 - 5. ATTENDING PHYSICIAN:
630438 - Randall E Lee, MD
630440 - ..
630441 - 6. PREOPERATIVE DIAGNOSIS:
630442 -
630443 - 1. Achalasia
630444 - 2. Peptic stricture
630446 - ..
630447 - 7. POSTOPERATIVE DIAGNOSIS:
630448 -
630449 - 1. Achalasia
630450 - 2. Peptic stricture s/p TTS balloon dilation
630452 - ..
630453 - 8. INDICATIONS:
630454 -
630457 -
630458 - 1. ...is a 67-year-old man with a history of achalasia. He
630459 - underwent laparoscopic myotomy and fundoplication at San
630460 - Francisco VA Medical Center, but then developed acid reflux
630461 - and a distal esophageal stricture that has required repeat
630462 - endoscopic dilations.
630464 - ..
630465 - 2. His last EGD and dilation was on April 2013, at which time
630466 - he had only mild mucosal trauma after inflation of a
630467 - balloon to 18 mm.
630469 - ..
630470 - 3. Triamcinolone acetate was injected into the stricture.
630472 - ..
630473 - 4. He was maintained on Omeprazole initially at 20 mg twice
630474 - daily for 1 month then dropped down to maintenance therapy
630475 - at 20 mg once daily.
630477 - ..
630478 - 5. He is now here for reevaluation.
630480 - ..
630481 - 6. In the Interim, he noted that his swallowing ability was
630482 - consistently maintained until about the last month when he
630483 - began noticing some dysphagia primarily to meet.
630485 - ..
630486 - 7. He has a co-diagnosis of coronary artery disease and
630487 - successfully underwent a coronary artery bypass and graft.
630489 - ..
630490 - 8. Earlier this year he succesfully climbed to the top of Half
630491 - Dome in Yosemite National Park.
630493 - ..
630494 - 9. CONSENT
630495 -
630496 - The risks, benefits, and alternatives to this procedure
630497 - including but not limited to the risks of bleeding and bowel
630498 - perforation were explained to the patient. The patient
630499 - understood and provided written informed consent.
630501 - ..
630502 - 10. INTRAVENOUS MEDICATIONS
630503 -
630504 - 1. Diphenhydramine 50 mg.
630505 - 2. Fentanyl 200 mcg.
630506 - 3. Midazolam 4 mg.
630508 - ..
630509 - 11. PROCEDURE:
630510 -
630511 - 1. In the Sacramento VA GI Endoscopy Unit, the patient was
630512 - placed in the left lateral decubitus position.
630514 - ..
630515 - 2. Oxygen at 2 liters per minute by nasal cannula was
630516 - administered. Continuous oximetric and hemodynamic
630517 - monitoring was initiated.
630519 - ..
630520 - 3. Intravenous sedation was administered in divided doses.
630522 - ..
630523 - 4. After a bite block was placed in the patient's mouth, an
630524 - Olympus GIFH180J videogastroscope was advanced under direct
630525 - vision into the esophagus.
630527 - ..
630528 - 5. A small amount of retained saliva within the esophagus was
630529 - easily irrigated and suctioned away.
630531 - ..
630532 - 6. At approximately 39 cm, there was an esophageal narrowing
630533 - with a small associated erosion, which did not impede
630534 - passage of the diagnostic endoscope. Endoscope was
630535 - advanced into the descending duodenum.
630537 - ..
630538 - 7. Retroflexed views of incisura, fundus, and cardia were
630539 - performed.
630541 - ..
630542 - 8. Random biopsies were taken from the antrum labeled A, from
630543 - the gastric body, from the GE junction at 39 cm labeled C.
630545 - ..
630546 - 9. A TTS balloon dilator was advanced across the distal
630547 - esophagus and inflated sequentially to 15, 16.5, and then
630548 - 18 mm. As visualized through the balloon, some small
630549 - amount of mucosal tearing was noted at 18 mm.
630551 - ..
630552 - This record is not clear whether the balloon engaged LESV anywhere
630553 - between 15-18mm, as reported for the prior procedure on 130416 1100.
630554 - ref SDS B4 Y850
630556 - ..
630557 - After the procedure, the doctor seemed to say LESV contracted back to
630558 - 16.5 mm, ref SDS 0 CO5N, but this is not expressly stated in Progress
630559 - Notes. ref SDS 0 RZ45
630560 -
630561 - LESV Dilated
630562 - Date from - to
630563 - 131115 16.5 18.....triamcinolone..2.0mL.... ref SDS 0 RZ45
630564 - 130416 18 18.....triamcinolone..2.0mL.... ref SDS B4 Y850
630565 - 130110 15 18.....triamcinolone..3.0mL.... ref SDS A9 Q333
630566 - 120925 15 18.....triamcinolone..4.0mL.... ref SDS 99 XB51
630567 - 120322 16.5 18............................. ref SDS 92 516N
630568 - 111115 16.5 18............................. ref SDS 90 IR57
630569 - 110819 15 16.5...triamcinolone..2.5mL.... ref SDS 87 J978
630570 - 110429 13 16.5...triamcinolone..3.5mL.... ref SDS 78 U23I
630571 - 110218 11 14.....triamcinolone..2.0mL.... ref SDS 73 AA5O
630572 - 101210 11 14............................. ref SDS 66 H347
630573 - 100827 11 15............................. ref SDS 49 JE6X
630574 - 100305 11 15............................. ref SDS 42 WR6L
630576 - ..
630577 - [On 140509 0900 Progress Notes are silent on triamcinolone
630578 - steriod injection - nothing is said except "...a small
630579 - amount of mucosal tearing" occurred dilating LESV,
630580 - ref SDS C1 P680, which appears conflicting with
630581 - understandings from post-procedure discussion with the
630582 - doctor seeming to indicate that triamcinolone injection was
630583 - not done because there was no tearing. ref SDS C1 O36G
630585 - ..
630586 - Progress Notes for EGD Dilation procedure on 131115 continue...
630587 -
630588 - 10. The balloon was deflated, removed, and 2 mm of
630589 - triamcinolone acetate at a concentration of 40 mg/mL were
630590 - injected into the areas of mucosal tearing.
630592 - ..
630593 - Continues prior protocol reported on 130416 1100. ref SDS B4 F38G
630594 - Aligns with discussion following meeting with the Doctor after the
630595 - procedure, shown above. ref SDS 0 I167
630597 - ..
630598 - Progress Notes for EGD Dilation procedure on 131115 continue...
630599 -
630600 - 11. The stomach was decompressed and the gastroscope removed.
630602 - ..
630603 - 12. Complications none.
630605 - ..
630606 - 12. FINDINGS:
630607 -
630608 - 1. Previous area of esophageal stricture again identified as
630609 - measured at 39 cm. This is coincident with the
630610 - gastroesophageal junction. Initial estimation of starting
630611 - diameter is 16.5 mm.
630613 - ..
630614 - Aligns with understandings meeting with the doctor, per above.
630615 - ref SDS 0 CO5N
630617 - ..
630618 - 2. As visualized under narrow band imaging, a suggestion of
630619 - columnar appearing mucosa immediately at the GE junction.
630620 - This was biopsied, labeled specimen C.
630622 - ..
630623 - Photographs taken during EGD procedure are stored in the record at...
630624 -
630625 - F:\05\00003\SM\CC\AGMJ\20131115-080024\Welch_11-22-13-photograph.docx
630627 - ..
630628 - 3. Shallow erosion in the squamous mucosa immediately above
630629 - the esophageal stenosis.
630631 - ..
630632 - 4. Gastric fundus surgically altered consistent with known
630633 - history of fundoplication.
630635 - ..
630636 - 5. Gastric antrum mucosa appears pale with a clear
630637 - demarcation line. This was biopsied, labeled specimen A.
630639 - ..
630640 - 6. Normal pylorus.
630642 - ..
630643 - 7. Normal duodenum to D2.
630645 - ..
630646 - 13. IMPRESSION:
630647 -
630648 - 1. Gastroesophageal reflux stricture with minor recurrence on
630649 - prior examination and dilation of April 2013.
630651 - ..
630652 - Citing procedure on 130416 1100. ref SDS B4 ZY41
630653 -
630654 -
630655 - 2. Atonic esophageal body with collection of saliva consistent
630656 - with known diagnosis of achalasia.
630658 - ..
630659 - 3. Fundoplication remains intact.
630661 - ..
630662 - See photograph...
630663 -
630664 - F:\05\00003\SM\CC\AGMJ\20131115-080024\Welch_11-22-13-photograph.docx
630665 -
630666 - [On 140509 0900 Progress Notes for follow up EGD
630667 - Dilation report Appearance of hiatal hernia suggests the
630668 - fundoplication appears to be loosening. ref SDS C2 I93F
630670 - ..
630671 - [On 141107,
630673 - ..
630674 - [On 150319 0800 meeting with Doctor Lee indicated acid
630675 - reflux increased causing ulceration and constriction to
630676 - LESV that hampers swallowing, because fundoplication has
630677 - unraveled, i.e., failed, ref SDS C3 N535; remedy -
630678 - referral to Doctor Stewart to assess re-fundoplication
630679 - or other measures. ref SDS C3 JQ5J
630681 - ..
630682 - 4. Gastritis within the antrum without evidence of malignancy,
630683 - erosion or ulceration.
630684 -
630686 - ..
630687 - 14. RECOMMENDATIONS:
630688 -
630689 - 1. Increase Omeprazole to 20 mg twice daily times 1 month,
630690 - then reduce back down to maintenance dosage of 20 mg once
630691 - daily.
630692 -
630693 - [On 131121 1604 ordered refill of Omeprazole to aid
630694 - digestion. There is 1 refill remaining. ref SDS B8 YS4O
630696 - ..
630697 - [On 131205 1443 received order for Omeprazole prescription
630698 - placed on 131121. ref SDS B9 5N3O
630700 - ..
630701 - 2. Repeat EGD and dilation in approximately 6 months.
630702 -
630703 - [On 140318 1043 received letter cancelling meeting
630704 - scheduled for EGD/Dilation procedure on 140425 1000,
630705 - ref SDS C0 935L; a second letter scheduled prodedure on
630706 - 140509 0900. ref SDS C0 5D7H
630708 - ..
630709 - 3. Await pathology results.
630710 -
630712 - ..
630713 - DISPOSITION:
630714 -
630715 - 1. The patient was observed in the Recovery Room then
630716 - discharged to home with companion.
630717 -
630718 - 2. I reviewed the endoscopic findings with the patient prior
630719 - to discharge.
630721 - ..
630722 - 15. TIME START:
630723 - 0847 hours
630725 - ..
630726 - TIME END:
630727 - 0909 hours.
630729 - ..
630730 - 16. D: 11/15/2013
630731 - T: 11/15/2013
630732 - Job number: 1192432
630733 - JLO/CMTS
630734 - $end:
630735 -
630736 - 17. /es/ RANDALL E LEE, MD
630737 - STAFF PHYSICIAN, GASTROENTEROLOGY
630738 - Signed: 11/20/2013 08:49
630739 -
630740 -
6308 -
SUBJECTS
VA EDG Biopsy Stomach Chronic Gastritis No Evidence Helicobacter Pyl
7803 -
780401 - ..
780402 - Biopsy Report Progress Notes EGD Dilation
780403 - Progress Notes EGD Dilation Biopsy Report
780404 -
780405 -
780406 - 18. 11/20/2013 ADDENDUM STATUS: COMPLETED
780407 -
780408 - Microscopic exam/diagnosis: (Date Spec taken: Nov 15, 2013)
780409 -
780410 - A. STOMACH, ANTRUM (BIOPSY):
780411 -
780412 - - CHRONIC GASTRITIS
780413 -
780414 - - NO EVIDENCE OF HELICOBACTER PYLORI BY WARTHIN STARRY
780415 - STAIN
780417 - ..
780418 - B. STOMACH, BODY (BIOPSY): CHRONIC GASTRITIS
780420 - ..
780421 - C. GASTROESOPHAGEAL JUNCTION, 39CM (BIOPSY):
780422 -
780423 - - SQUAMOCOLUMNAR MUCOSA WITH ACUTE AND CHRONIC
780424 - INFLAMMATION
780425 -
780426 - - NEGATIVE FOR INTESTINAL METAPLASIA (BARRETT'S
780427 - ESOPHAGUS)
780428 -
780430 - ..
780431 - 19. In Reply Refer to: Sacramento VA
780432 -
780433 - Gastroenterology (111G/SMAT)
780434 - Mr. Rodney C Welch
780435 - 1158 St Matthew Place
780436 - Unit 103
780437 - Concord CA 94518
780438 -
780439 -
780440 - *******************************************
780441 -
780442 -
780443 -
7805 -
SUBJECTS
Letter VA Doctor Summary Results EGD Dilation Biopsy Medical Chart P
9303 -
930401 - ..
930402 - 1. LOCAL TITLE: Pre-Procedure Note 60302
930403 - STANDARD TITLE: PROCEDURE NOTE
930404 - DATE OF NOTE: NOV 15, 2013@08:00 ENTRY DATE: NOV 15, 2013@08:28:47
930405 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
930406 - URGENCY: STATUS: COMPLETED
930407 -
930408 - *** Pre-Procedure Note 60302 Has ADDENDA ***
930410 - ..
930411 - DATE AND TIME OF PROCEDURE: Nov 15,2013@08:00
930413 - ..
930414 - 2. CONSENT (select ONE option): I-Med note by procedure prov
930416 - ..
930417 - 3. PROCEDURE: egd dilation
930419 - ..
930420 - 4. PROVIDER: rlee
930422 - ..
930423 - 5. INDICATION: esophageal stenosis
930425 - ..
930426 - 6. ALLERGIES: Reviewed; CPRS up to date
930428 - ..
930429 - 7. SITE: egd
930431 - ..
930432 - 8. SIDE: N/A
930434 - ..
930435 - 9. CHECKLIST ITEMS:
930436 -
930437 - 1. Name confirmed
930438 - 2. DOB confirmed
930439 - 3. SSN confirmed
930440 - 4. MD/Pt confirmed procedure
930441 - 5. All equipment good to go
930442 - 6. All staff in agreement
930444 - ..
930445 - 10. CHECKLIST STATUS: Items 1-6 have been confirmed
930446 -
930448 - ..
930449 - 11. CONSCIOUS SEDATION PRE-PROCEDURE NOTE:
930450 - ASA Level: 2.0
930452 - ..
930453 - 12. MD/DENTIST/NP ASSESSMENT:
930454 -
930455 - 1. PATIENT HISTORY:
930456 - NEURO:
930457 - Stroke/Encephalopathy: No
930458 -
930459 - AIRWAY:
930460 - Prior problems with intubation: No
930461 - Recent stridor/snoring: No
930463 - ..
930464 - RESP:
930465 - Chronic Bronchitis/Emphysema/Asthma: No
930466 - No history of OSA.
930468 - ..
930469 - INFECTIOUS DISEASE:
930470 - AIDS/Hepatitis: No
930472 - ..
930473 - GI/GU:
930474 - Kidney Disease: No
930475 - Liver Disease: No
930477 - ..
930478 - ENDOCRINE:
930479 - Diabetes? No
930481 - ..
930482 - CV:
930483 - HTN: No
930484 - MI/Angina: CABG; asymptomatic
930485 - CHF: No
930486 - AICD/Pacemaker: No
930487 - Prosthetic Heart Valve: No
930489 - ..
930490 - OTHER:
930491 - Tobacco: No
930492 - ETOH: No
930494 - ..
930495 - 2. PHYSICAL ASSESSMENT:
930496 -
930497 - 1. Vitals - most recent
930498 -
930499 - Temp:96.7 F [35.9 C] (11/15/2013 07:32)
930500 - BP: 122/82 (11/15/2013 07:32)
930501 - HR: 60 (11/15/2013 07:32)
930502 - RR: 18 (11/15/2013 07:32)
930503 - WT: 173 lb [78.6 kg] (11/15/2013 07:32)
930504 - HT: 66 in [167.6 cm] (11/15/2013 07:32)
930506 - ..
930507 - 2. Mental Status: Alert, Oriented to: person, place,
930508 - date, situation,
930510 - ..
930511 - 3. Oriented to: situation
930513 - ..
930514 - 4. Airway: Can patient open mouth wide? Yes
930515 - Can patient stick out tongue? Yes
930516 - Restricted movement of the neck? No
930517 - Uvula fully visible when mouth open? Yes
930518 - Comments:
930520 - ..
930521 - 5. Lungs: CTA Bilaterally
930523 - ..
930524 - 6. Heart: REGULAR, NO MURMURS
930526 - ..
930527 - 7. Exam specific to procedure:
930528 -
930530 - ..
930531 - 13. Medications:
930532 -
930533 - Active Outpatient Medications (excluding Supplies):
930535 - ..
930536 - OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH ACTIVE
930537 - TWICE A DAY -15 MINUTES BEFORE MEALS FOR ACID
930538 - REFLUX.
930539 -
930541 - ..
930542 - 14. Diagnostics: No new diagnostics reguired.
930543 -
930544 - Pertinent diagnostic data has been reviewed, significant
930545 - findings
930546 - below:
930548 - ..
930549 - 15. Date and time of last oral intake: Nov 15,2013@06:00
930551 - ..
930552 - 16. Nature (type) and amount of last oral intake: See RN note
930554 - ..
930555 - 17. SEDATION PLAN:
930556 -
930557 - Sedation/Anesthesia options, benefits, and risks were discussed
930558 - including: nausea/vomiting, allergic reactions, unexpected
930559 - cardiac or pulmonary problems, and cardiac arrest. Patient
930560 - expressed understanding and wishes to proceed with planned
930561 - sedation/anesthesia.
930563 - ..
930564 - 18. Did a family member or companion accompany the patient and
930565 - participate in the discussion and Interview? No
930566 -
930567 - 19. /es/ RANDALL E LEE, MD
930568 - STAFF PHYSICIAN, GASTROENTEROLOGY
930569 - Signed: 11/15/2013 08:30
930570 -
930571 - 20. 11/15/2013 ADDENDUM STATUS: COMPLETED
930572 - EGD 1192432: TTS balloon engaged at 16.5mm
930573 - dilated to 18mm; triamcinolone 40mg/ml x 2ml injected.
930574 -
930575 - 21. /es/ RANDALL E LEE, MD
930576 - STAFF PHYSICIAN, GASTROENTEROLOGY
930577 - Signed: 11/15/2013 08:30
930578 -
930579 -
930580 - ********************************************
930581 -
930582 - 1. LOCAL TITLE: Informed Consent 20303
930583 - STANDARD TITLE: PROCEDURE CONSENT
930584 - DATE OF NOTE: NOV 15, 2013@08:21:52 ENTRY DATE: NOV 15, 2013@08:22:14
930585 - AUTHOR: SALERA,RODELEI M EXP COSIGNER:
930586 - URGENCY: STATUS: COMPLETED
930587 - Signature Informed Consent for
930588 - EGD WITH POSSIBLE INTERVENTIONS (VA) (ESOPHAGOGASTRODUODENOSCOPY
930589 - (EGD) WITH POSSIBLE INTERVENTIONS)
930590 -
930591 - 1. Anatomical Location: EGD WITH DILATION
930593 - ..
930594 - 2. Informed consent was obtained at 8:21 AM on November 15,
930595 - 2013. The full consent document can be accessed through
930596 - Vista Imaging.
930598 - ..
930599 - 3. Patient name: WELCH, RODNEY CHARLES
930601 - ..
930602 - 4. The patient HAS decision-making capacity.
930604 - ..
930605 - 5. Surrogate (if applicable):
930607 - ..
930608 - 6. Reason for the treatment (diagnosis, condition, or
930609 - indication): To examine and treat the esophagus, stomach,
930610 - and first part of small intestine for abnormalities and
930611 - disease.
930613 - ..
930614 - 7. Treatment/procedure: Upper GI endoscopy or
930615 - esophagogastroduodenoscopy (EGD) is a procedure to look
930616 - at and treat problems in your esophagus (swallowing
930617 - tube), stomach, and first part of your small intestine
930618 - (duodenum). A flexible, steerable tube (endoscope) will
930619 - be used. This tube has a light, camera and openings for
930620 - tools. Before the procedure starts, your throat may be
930621 - sprayed with some numbing medication. After that, you
930622 - may be given medicine to make you sleepy (sedation).
930623 - After you are sleepy, the tube will be passed through
930624 - your mouth and into your esophagus, stomach, and
930625 - duodenum.
930627 - ..
930628 - Several things can be done with the endoscope, depending
930629 - on what is found. These include:
930630 -
930631 - 1. Take photographs.
930632 -
930633 - 2. Remove samples of tissue (biopsies).
930635 - ..
930636 - 3. Remove growths.
930638 - ..
930639 - 4. Control or prevent bleeding by injecting medicines,
930640 - applying heat (cautery) or placing clips or rubber
930641 - bands.
930643 - ..
930644 - 5. Stretch narrow areas with balloons or tapered
930645 - plastic dilators.
930647 - ..
930648 - 6. Other things the doctor thinks are necessary.
930650 - ..
930651 - 8. Moderate sedation will be used.
930653 - ..
930654 - 9. Consent to Blood Products (if applicable):
930655 -
930656 - It is not expected that blood products will be used in this
930657 - treatment/procedure.
930659 - ..
930660 - 10. Practitioner obtaining consent: Lee,Randall E (STAFF
930661 - PHYSICIAN)
930663 - ..
930664 - 11. Supervising practitioner:
930666 - ..
930667 - 12. Practitioner(s) performing or supervising
930668 - treatment/procedure (if not listed above):
930670 - ..
930671 - 13. Witness Name(s):
930673 - ..
930674 - 14. Comments:
930676 - ..
930677 - 15. Comprehension Check Procedure2|DM
930679 - ..
930680 - *** SCANNED DOCUMENT ***
930681 - SIGNATURE NOT REQUIRED
930682 - Electronically Filed: 11/15/2013
930683 -
930684 - by: IMED IMED-SERVER
930685 -
930686 -
930687 - *************************************
930688 -
930689 -
930690 - 1. LOCAL TITLE: Gastroenterology Nurse Note 60133
930691 - STANDARD TITLE: GASTROENTEROLOGY NURSING NOTE
930692 - DATE OF NOTE: NOV 15, 2013@07:33 ENTRY DATE: NOV 15, 2013@07:33:34
930693 - AUTHOR: ABUYUAN,JOECIMEN EXP COSIGNER:
930694 - URGENCY: STATUS: COMPLETED
930696 - ..
930697 - 2. ADM TIME: Nov 15,2013@07:33
930699 - ..
930700 - 3. Vitals - most recent
930701 -
930702 - 1. Temp: 96.7 F [35.9 C] (11/15/2013 07:32)
930703 - 2. BP: 122/82 (11/15/2013 07:32)
930704 - 3. HR: 60 (11/15/2013 07:32)
930705 - 4. RR: 18 (11/15/2013 07:32) 02 Sat:
930706 - 5. FBS: na
930707 - 6. RA/02@LPM
930708 - 7. Pain: 0 (11/15/2013 07:32)
930709 - 8. Location:
930710 -
930711 - ********************************************************
930713 - ..
930714 - 4. YES
930715 -
930716 - 1. PATIENT ID: Verbal, ID Band, Chart
930718 - ..
930719 - 5. Allergies: Patient has answered NKA
930720 - Allergy information verified: YES
930721 -
930722 - 2. Nothing entered...
930724 - ..
930725 - 6. No
930726 -
930727 - 3. Advance Directive
930728 -
930729 - a. Patient has an Advance Directive in Medical Record
930730 -
930731 - b. Patient provided us with a copy of Advance
930732 - Directive today
930733 -
930735 - ..
930736 - 7. YES
930737 -
930738 - 4. H&P in chart (within 30 days) Read & Reviewed
930740 - ..
930741 - 8. YES
930742 -
930743 - 5. Consent Signed, Dated & Timed (within 30 days)
930745 - ..
930746 - 9. Patient verbally verified:
930748 - ..
930749 - 10. YES
930750 -
930751 - 6. Correct Procedure
930753 - ..
930754 - 11. YES
930755 -
930756 - 7. NPO Since:Time & Date:Nov 14,2013@20:00
930757 - Last Solid Food: Nov 14,2013@16:00
930759 - ..
930760 - NA
930761 -
930762 - 8. Bowel Prep Completed
930763 - Color of last Bowel Movement:
930764 - Fleets enema given: N/A Time:
930765 - Results: Administered By:
930767 - ..
930768 - 12. YES
930769 -
930770 - 9. MD Orders, Nursing Assessment Completed
930772 - ..
930773 - 13. YES
930774 -
930775 - 10. Implants:
930776 -
930777 - Type: cabg x 4 Locations: chest
930779 - ..
930780 - 14. YES
930781 -
930782 - 11. Patient Valuables: Gurney
930783 -
930784 - 12. Skipped for some reason
930786 - ..
930787 - 15. NO
930788 -
930789 - 13. Dentures:
930791 - ..
930792 - 16. NO
930793 -
930794 - 14. Glasses/Contact Lenses:
930796 - ..
930797 - 17. NO
930798 -
930799 - 15. Skipped for some reason
930801 - ..
930802 - 18. YES
930803 -
930804 - 16. Driver/Escort Waiting If yes,
930805 -
930806 - Name: Cathy, sis in law
930808 - ..
930809 - 19. YES
930810 -
930811 - 17. Post Procedure Instructions Reviewed with Patient, Driver/Escort
930812 -
930813 - Date of Interview: NOV 15, 2013 Patient Age: 68
930814 - Physician: lee
930815 - Procedure: egd
930817 - ..
930818 - 20. Upon arrival patient was offered the option to don a hospital
930819 - gown and have an IV placed prior to seeing the GI practitioner.
930820 - Patient verbally consented to don gown and have an IV placed.
930822 - ..
930823 - 21. Patient was provided with a signaling device, and he/she was
930824 - instructed to activate it at any time if he/she wishes to abort
930825 - the planned procedure.
930827 - ..
930828 - 22. CURRENT MEDICATIONS TAKEN TODAY: None
930830 - ..
930831 - 23. Are you using Fentanyl Patches? no
930832 - If Yes, when was the last time applied?
930834 - ..
930835 - 24. Diabetic (IDDM): no
930836 - Last dose:
930837 - Diabetic (NIDDM): no
930839 - ..
930840 - 25. ASA: no
930841 - Last dose:
930843 - ..
930844 - 26. NSAIDS: no
930845 - Last dose:
930847 - ..
930848 - 27. Anti-platelets Therapy: no
930850 - ..
930851 - 28. Anticoagulation Therapy: no
930853 - ..
930854 - 29. LOC:AAO
930855 - Cognitive Limitations: None
930857 - ..
930858 - 30. Circ/Perfusion: Warm
930860 - ..
930861 - 31. Heart Tones: Distant
930862 - cabg x 4
930863 - Respirations: Regular
930865 - ..
930866 - 32. GI: Soft, Non-Tender, Bowel Sounds; present on omeprAZOLE
930867 - GU: Voids w/o problems
930868 - Comments:
930870 - ..
930871 - 33. GYN: NA
930873 - ..
930874 - 34. Skin: Intact
930875 - Comments:
930877 - ..
930878 - 35. Musc/Skeletal/Activity: No abnormal finding Mobility:
930880 - ..
930881 - 36. Manual Dexterity:
930883 - ..
930884 - 37. Comments:
930886 - ..
930887 - 38. Behavioral/Emotional Status: Calm, Cooperative
930888 - Comments:
930890 - ..
930891 - 39. Barriers to Learning/Functional Assessment:
930892 - Vision: Unimpaired
930894 - ..
930895 - 40. Hearing: Unimpaired
930897 - ..
930898 - 41. Communication: Normal
930900 - ..
930901 - 42. Interpreter Required: no
930903 - ..
930904 - 43. Nutritional Assessment: Special Diet Restrictions
930905 - HERE FOR EGD WITH DILATION. STAYS AWAY FROM MEAT
930907 - ..
930908 - 44. Cultural/Religious Preferences: none
930910 - ..
930911 - 45. PLAN OF CARE - Pre-Procedure Sedation
930913 - ..
930914 - 46. Knowledge deficit related to impending procedure
930915 - Outcomes: Patient has adequate and appropriate information
930916 - related to pre-procedure, intra-procedure, and post-procedure
930918 - ..
930919 - 47. Instruct patient at initial visit that he/she must arrive with
930920 - a responsible adult to transport them following the procedure.
930921 - Procedure will be re-scheduled if arrangements not made.
930923 - ..
930924 - 48. Explain purpose of pre procedure sedation
930926 - ..
930927 - 49. Explain how conscious sedation works
930929 - ..
930930 - 50. Explain monitoring of vital signs/patient pain status
930931 - throughout procedure.
930933 - ..
930934 - 51. Enroll patient in procedure class
930936 - ..
930937 - 52. Above actions completed
930939 - ..
930940 - 53. PLAN OF CARE - Intra- Procedure SEDATION
930941 - Potential for anxiety related to possible pain during
930942 - impending procedure and unfamiliar environment
930944 - ..
930945 - 54. Outcomes: Patient shows no signs of anxiety and verbalizes
930946 - decreased level of anxiety during procedure.
930948 - ..
930949 - 55. Allow private time 1 on 1 with patient to discuss fear or
930950 - concerns
930952 - ..
930953 - 56. Explain monitoring of vital signs/patient pain status
930954 - throughout procedure.
930956 - ..
930957 - 57. Discuss medications and how patient is monitored
930959 - ..
930960 - 58. Ask patient if he/she or someone he/she knows has ever had an
930961 - untoward reaction to sedation ... encourage discussion
930963 - ..
930964 - 59. Discuss any problems patient may have had with breathing,
930965 - airway obstruction in past.
930967 - ..
930968 - 60. Above actions completed
930970 - ..
930971 - Number 59 was not done in that there was no discussion of breathing,
930972 - airway obstruction, which occurred previously following CABG surgery,
930973 - reported on 091023 0445. ref SDS 17 01F9
930975 - ..
930976 - Nurses Notes continue...
930977 -
930978 - 61. Potential for risk for altered gas exchange and ineffective
930979 - breathing patterns secondary to sedation
930980 -
930981 - 62. Outcomes: Patient will exhibit no signs of respiratory
930982 - distress and airway will remain patent throughout the procedure
930984 - ..
930985 - 63. Nurse will assess current allergies and update documentation
930986 - of allergies in CPRS
930988 - ..
930989 - 64. Nurse will verify/maintain NPO status
930991 - ..
930992 - 65. Nurse will assure that all equipment in close proximity and in
930993 - working order prior to procedure
930995 - ..
930996 - 66. Nurse administering conscious sedation will keep noise level
930997 - to a minimum.
930999 - ..
931000 - 67. Nurse will remain alert to subtle changes such as dyspnea,
931001 - hyperventilation, cyanosis, shortness of breath or stridor in
931002 - breathing patterns and possible drop in oxygen saturation
931003 - and/or hypotension keeping physician informed of patient status
931004 - during procedure.
931006 - ..
931007 - 68. Above actions completed
931009 - ..
931010 - 69. Potential for actual pain during procedure
931012 - ..
931013 - 70. Outcome: Patient will verbalize or demonstrate relief of pain
931014 - during and post-procedure.
931016 - ..
931017 - 71. Nurse will assess level of pain throughout the procedure and
931018 - administer analgesic as needed per order and evaluate
931019 - effectiveness.
931021 - ..
931022 - 72. Above actions completed
931024 - ..
931025 - 73. PLAN OF CARE -Post- Procedure SEDATION
931027 - ..
931028 - 74. Potential for altered level of consciousness or sensory motor
931029 - deficit at discharge
931031 - ..
931032 - 75. Outcome: Patient will remain free of injury and will be
931033 - oriented x 3 prior to discharge.
931035 - ..
931036 - 76. Patient will be fully awake and oriented, exhibit the ability
931037 - to cough and deep breath prior to discharge, ambulate with
931038 - steady gain as appropriate per pre-procedure, with minimal
931039 - pain, and minimal nausea.
931041 - ..
931042 - 77. Above actions completed
931044 - ..
931045 - 78. Potential knowledge deficit for self care
931047 - ..
931048 - 79. Outcome: Patient and/or caregiver will verbalize an
931049 - understanding of discharge instructions
931051 - ..
931052 - 80. Discharge instructions will be provided to patient. Nurse will
931053 - assure all questions are answered, and have patient repeat
931054 - instructions as they understood them. Nurse will individualize
931055 - teaching based on patients' ability to understand.
931057 - ..
931058 - This was not actually done. Patient received a blank discharge form,
931059 - unsigned. Driving home, discussed with Kathy the doctor's
931060 - post-procedure comments. On arriving home, Kathy wrote down what she
931061 - recalled the doctor said, which is different from the patient's
931062 - recollection, which was imparied from sedation.
931064 - ..
931065 - Previously, when procedures were performed at the Martinez Clinic, the
931066 - doctor entered discharge instructions and summarized key results,
931067 - shown by the record on 110429 1230. ref SDS 78 DU6J
931069 - ..
931070 - For prior procedures, the admitting attendant asked the patient to
931071 - sign a blank discharge document before any work was performed. This
931072 - was refused, reported on 110429 1230. ref SDS 78 SR8M
931074 - ..
931075 - Nurses Notes continue...
931076 -
931077 - 81. Nurse will place follow-up call to patient the following work
931078 - ay of procedure.
931080 - ..
931081 - Josie said she or someone will call next Monday to follow up work
931082 - today. She was advised patient will be traveling Sunday, and out of
931083 - town until Thursday, 131121, and will get telephone messages at that
931084 - time.
931086 - ..
931087 - Nurses Notes continue...
931088 -
931089 - 82. Assure patient doing well post-procedure, answer questions and
931090 - reinforce dates for follow-up, if any.
931092 - ..
931093 - 83. Above actions completed
931094 -
931095 - 84. /es/ Joecimen Abuyuan, BSN, RN
931096 - Staff Nurse, GI
931097 - Signed: 11/15/2013 07:40
931098 -
931099 -
931100 -
931101 -
9312 -
SUBJECTS
Default Null Subject Account for Blank Record
9403 -
9404 -
940401 -
940402 - 1. LOCAL TITLE: Gastroenterology Nurse Note 60133
940403 - STANDARD TITLE: GASTROENTEROLOGY NURSING NOTE
940404 - DATE OF NOTE: NOV 15, 2013@07:40 ENTRY DATE: NOV 15, 2013@07:40:40
940405 - AUTHOR: ABUYUAN,JOECIMEN EXP COSIGNER:
940406 - URGENCY: STATUS: COMPLETED
940408 - ..
940409 - Immediate Pre-Sedation Evaluation
940411 - ..
940412 - 2. ASA Classification: 2
940413 - 3. NPO: Yes
940414 - 4. Last ate: 11/15 1600
940415 - 5. Driver: YES
940416 - 6. Took Meds: No
940417 - 7. AM GLU: NA
940418 - 8. Off Aspirin: Yes
940419 - 9. Off NSAID: YES
940421 - ..
940422 - 10. Vital Signs:
940423 -
940424 - 1. BP: 122/82 (11/15/2013 07:32)
940425 - 2. Temp: 96.7 F [35.9 C] (11/15/2013 07:32)
940426 - 3. Pulse: 60 (11/15/2013 07:32)
940428 - ..
940429 - 11. Heart: CABG X 4
940430 - 12. Lungs: WNL
940431 - 13. Implants: CABG
940432 - 14. ETOH use? No
940433 - 15. Chronic pain Medication use? No
940434 - 16. Drug use? No
940435 - 17. Tobacco use? No
940437 - ..
940438 - 18. Additional Comments:
940439 -
940440 - achalasia,fundoplication. FOR EGD WITH possible repeat
940441 - dilation
940443 - ..
940444 - No change in medical condition since seen for anesthesia
940445 - pre-op. Patient
940446 - agrees to proceed.
940448 - ..
940449 - 19. A procedure was done using an endoscope with the following
940450 - serial number
940451 - [SCOPE 1]:
940452 -
940453 - Serial#: GIF 4645
940454 -
940455 - /es/ Joecimen Abuyuan, BSN, RN
940456 - Staff Nurse, GI
940457 - Signed: 11/15/2013 08:31
940458 -
940459 -
940460 - *************************************
940461 -
940462 -
940463 -
940464 -
940465 -
940466 -
940467 -
9405 -
SUBJECTS
Discharge Instructions Blank VA EGD Procedure Stricture Lower Esopha
A903 -
A90401 - ..
A90402 - Discharge Instructions Blank No Signature No Date
A90403 -
A90404 -
A90405 - 1. LOCAL TITLE: GI Discharge Instructions
A90407 - ..
A90408 - 2. VANCHCS GI Clinic Discharge Instructions::
A90410 - ..
A90411 - 3. -Do not drive a motor vehicle, operate machinery, or make
A90412 - important decisions for at least 24 hours after your procedure.
A90413 - The medication given during your procedure may make you dizzy
A90414 - and sleepy and will affect how you act and think.
A90416 - ..
A90417 - 4. -You may resume a normal diet after you leave today unless
A90418 - instructed otherwise. However, for the first meal please eat
A90419 - light food, nothing greasy or spicy.
A90421 - ..
A90422 - 5. -During your procedure the doctor added air into your GI tract
A90423 - so you may experience some abdominal bloating and cramping.
A90424 - The sooner you can pass the air the better you will feel. The
A90425 - discomfort or bloating will subside in a few hours but may last
A90426 - all day.
A90428 - ..
A90429 - 6. -If you have any of the following symptoms, please call the
A90430 - clinic at (916) 366-5339 for advice.
A90431 -
A90432 - A. Passing or vomiting large amounts of blood.
A90433 - B. Passing black or tarry stools.
A90434 - C. Fever over 100° with or without chills.
A90435 - D. Severe tenderness or redness at IV needle puncture
A90436 - site.
A90437 - E. Severe abdominal or chest pain.
A90438 - F. Shortness of breath or tightness in the chest.
A90439 - G. Loss of consciousness or frequent bouts of dizziness.
A90440 -
A90442 - ..
A90443 - 7. -MEDICATIONS: You may resume your medications after the
A90444 - procedure unless instructed otherwise by your physician.
A90446 - ..
A90447 - 8. Resume ALL MEDS on Nov 15,2013
A90449 - ..
A90450 - 9. EGD, EUS, or Enteroscopy:
A90452 - ..
A90453 - 10. -a mild sore throat can be helped by cough drops, or a
A90454 - salt-water gargle.
A90456 - ..
A90457 - 11. -Wait a half-hour after the exam before drinking liquids, as
A90458 - oral anesthetic may have been used to numb the throat.
A90460 - ..
A90461 - 12. -Call or return to ER if difficulty swallowing or breathing,
A90462 - neck swelling, excessive pain, nausea or vomiting, abdominal
A90463 - distension, fever.
A90465 - ..
A90466 - 13. GI Clinic phone number (916) 366-5339 (8:00am-4:30pm)
A90467 - After 4:30pm, weekends and holidays, please call (800) 382-8387
A90469 - ..
A90470 - 14. Follow Up:
A90471 - Primary Provider
A90473 - ..
A90474 - 15. POST-OP INSTRUCTION given to patient and responsible adult.
A90475 - Verbalized understanding.
A90477 - ..
A90478 - 16. If you would like a copy of your procedure report, please
A90479 - contact Release of Information (ROI) at (916) 843 7005.
A90480 -
A90481 - /es/ Laramie Samson, RN
A90482 - Staff Nurse, GI Clinic
A90483 - Signed: 11/15/2013 10:06
A90485 - ..
A90486 - This part of the medical chart varies somewhat from Discharge form
A90487 - received after recovery.
A90489 - ..
A90490 - The form is blank.
A90492 - ..
A90493 - Kathy wrote some notes from memory of Doctor Lee's discussion with
A90494 - the patient.
A90495 -
A90496 -
A90497 -
A90498 -
A90499 -
A90500 -
A90501 -
A90502 -
A906 -
SUBJECTS
Letter VA Doctor Summary Results EGD Dilation Biopsy Medical Chart P
AO03 -
AO0401 - ..
AO0402 - Letter Doctor Summary Results EGD Dilation Biopsy
AO0403 -
AO0404 -
AO0405 -
AO0406 - 1. 20 November 2013
AO0411 - ..
AO0412 - 2. You had an endoscopic examination of your esophagus, stomach,
AO0413 - and duodenum (EGD) with at the Sacramento VA Medical Center on
AO0414 - 15 November 2013. I'm pleased to report that the examination
AO0415 - and biopsies showed NO cancer, precancerous changes
AO0416 - (dysplasia), ulcer, or infection.
AO0418 - ..
AO0419 - 3. You continue to have some chronic inflammation of the stomach
AO0420 - (gastritis) and esophagus, so we should continue the
AO0421 - acid-blocking medication (omeprazole) every day. As we
AO0422 - discussed, please take the omeprazole twice a day for 1 month
AO0423 - after the EGD and dilation, then you can reduce the omeprazole
AO0424 - to 20mg from twice a day to once a day, 15 to 30 minutes before
AO0425 - a meal.
AO0427 - ..
AO0428 - 4. We should repeat the EGD in about 6 months (about May 2014).
AO0430 - ..
AO0431 - 5. My best wishes to you this holiday season, early Happy Birthday
AO0432 - wishes, and congratulations again on your joining the "Half
AO0433 - Dome Club."
AO0435 - ..
AO0436 - Truly yours,
AO0437 -
AO0439 - ..
AO0440 - Randall E Lee, MD, FACP
AO0441 - Gastroenterologist, VA NCHCS
AO0442 - 916-366-5339
AO0443 -
AO0444 - 6. /es/ RANDALL E LEE, MD
AO0445 - STAFF PHYSICIAN, GASTROENTEROLOGY
AO0446 - Signed: 11/20/2013 08:58
AO0447 -
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