CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10
2503 -
2503 - ..
2504 - Summary/Objective
2505 -
250501 - Follow up ref SDS D3 0000. ref SDS C4 0000.
250502 -
250503 - Met with Doctor Lee at VA Medical Center in Sacramento (Mather).
250504 - Checking in and initial administration went well. ref SDS 0 GD4H
250505 - Preparation for the procedure was professional; no difficulties
250506 - setting IV for conscious sedation today. ref SDS 0 544G The doctor
250507 - reported not receiving letter with agenda for the meeting today,
250508 - submitted on 151201. ref SDS 0 VV6N Diffuculty swallowing this cycle
250509 - did not occur until after 5 months, because triamcinalone steriod was
250510 - injected during prior procedure on 150421. Swallowing difficulty with
250511 - increased vomiting over the next 3 months indicates better outcome
250512 - will occur dilating LESV 18 mm and doing next EGD dilation in 6
250513 - months, rather than 8 months. ref SDS 0 P55L Asked about using Baking
250514 - Soda to clear throat in order to avoid vomitting, and prevent
250515 - ulceration LESV alternative to Omeprazole in order to avoid side
250516 - effects causing dehydration. ref SDS 0 G53K Performing EGD dilation
250517 - procedure went smoothly, with no reports of difficulties. ref SDS 0
250518 - 7V6I Post procedure Doctor Lee reported LESV contracted to 10 mm, the
250519 - smallest diameter in patient history, indicating 2 month delay to 8
250520 - months performing the procedure this cycle was significantly harmful.
250521 - ref SDS 0 5H5J
250522 -
250523 - [On 151210 0800 follow up meeting Doctor Lee ordered 4
250524 - bottles Mylanta for enough to last until next EGD dilation
250525 - meeting in 3-4 months OA 160304, ref SDS F5 OD6O; and he
250526 - changed prescription from Ranitidine to Famotidine because
250527 - they do the same thing, but Famotidine pills are smaller
250528 - and so easier to swallow, he ordered 4 month supply.
250529 - ref SDS F5 YL3M
250531 - ..
250532 - [On 151210 0800 following meeting with Doctor Lee to
250533 - clarify and adjust medication protocols, Jessica reminded
250534 - to notify her on 160104 to schedule next EGD dilation in
250535 - March, because VAMC computer in Sacramento will not support
250536 - scheduling meeting with doctors more than 3 months in
250537 - advance. ref SDS F6 KT6M
250539 - ..
250540 - [On 160104 1349 letter to Jessica in GI Clinic to schedule
250541 - next EGD dilation meeting on 160304. ref SDS F9 HU55
250543 - ..
250544 - [On 160106 2131 letter to Doctor Lee confirms planning for
250545 - EGD dilations on 3 month intervals, and schedule next EGD
250546 - dilation OA 160304 0800. ref SDS G1 T257
250548 - ..
250549 - [On 160126 0004 letter notifies Doctor Lee at GI Clinic in
250550 - VA Medical Center at Sacramento Mather Air Force Base, that
250551 - Doctor Stewart in Surgery Clinic requested 2 EGD dilations
250552 - on 3 month intervals to support follow up evaluation for
250553 - surgical solution to achalasia (Dor fundoplication) issue,
250554 - which requires next EGD dilation OA 160304. ref SDS G2 NU8L
250556 - ..
250557 - [On 160208 1031 called VAMCSAC talked to Jessica; she
250558 - scheduled next EGD dilation on 160315 0900, ref SDS G3
250559 - VB9P; and scheduled next consult on 160405 0930.
250560 - ref SDS G3 VB96
250561 -
250562 -
250563 -
250564 -
250565 -
250566 -
250567 -
250569 - ..
2506 -
2507 -
2508 - Background
2509 -
250901 - On 050629 meeting Primary Care swallowing and vomitting problems
250902 - reported. ref SDS 1 K78K
250904 - ..
250905 - On 050714 barrium swallow test, ref SDS 2 2I4S, showed esophagus
250906 - distorted by swallowing problems. ref SDS 2 WE4H
250908 - ..
250909 - On 050816 meeting Primary Care Doctor Sandhu diagnoses achalasia.
250910 - ref SDS 3 DG8G Ultrasound test ordered to verify initial diagnosis of
250911 - swallowing and vomitting problems. ref SDS 3 6E7H Primary Care made
250912 - referral to GI clinic for care to resolve swallowing problems.
250913 - ref SDS 3 0G7M
250915 - ..
250916 - On 050830 ultrasound test evaluate swallowing problems possible
250917 - diagnosis achalasia. ref SDS 4 DG8G
250919 - ..
250920 - On 050830 results received barrium swallow test performed on 050714,
250921 - findings in the lower espohagus and gastroesophageal junction are
250922 - consistent with achalasia - recommend endoscopic examination.
250923 - ref SDS 4 6H9S
250925 - ..
250926 - On 050906 report ultrasound test on 050830, finds no cause for
250927 - swallowing problems and does not diagnose achalasia. ref SDS 5 BM6R
250929 - ..
250930 - On 051202 meeting GI Clinic Doctor Lee diagnoses achalasia.
250931 - ref SDS 6 HP9H Orders endoscopy (EGD) test to verify diagnosis of
250932 - achalasia and assess for cancer. ref SDS 6 NZ5H
250934 - ..
250935 - On 051209 GI Clinic endoscopy examination preliminary findings no
250936 - evidence of cancer, ref SDS 7 0001; biopsy report should be submitted
250937 - in a few weeks to confirm status of cancer, ref SDS 7 PY5J, and if so,
250938 - then a procedure can be schedule for next month to dilate the
250939 - exophageal sphincter valve. ref SDS 7 NZ5H
250941 - ..
250942 - On 051222 biopsy reports no evidence of cancer. ref SDS 8 FT6M
250944 - ..
250945 - On 060111 received letter from Doctor Lee in the Gastrointestinal (GI)
250946 - Clinic reporting that the biopsy was negative for cancer and
250947 - infection; next step is manometry test to verify achalasia, then
250948 - treatment for achalasia. ref SDS 9 4Q3R
250950 - ..
250951 - On 060125 manomety test scheduled for 060209 0800. ref SDS 10 GG9I
250953 - ..
250954 - On 060209 meeting at VA Mather AFB in Sacramento, test was postponed
250955 - until 060223, due to equipment failure. ref SDS 11 OW6M
250957 - ..
250958 - On 060221 Jimmy in GI Department at Sacramento VA Medical Center
250959 - reports manometry equipment still broken; has been sent out for
250960 - repairs and there is no date at this time on when the equipment will
250961 - be available for use at the VA. ref SDS 12 ND7M
250963 - ..
250964 - On 060330 endoscopy follow up examination at GI Department Sacramento
250965 - Medical Center - Doctor Lee finds no evidence cancer performed at VA
250966 - Sacramento condition precedent treatment recover from achalasia.
250967 - ref SDS 13 VX4G
250969 - ..
250970 - On 060330 manometry test performed by Doctor Lee at VA in Sacramento,
250971 - ref SDS 13 MC7P, verifies diagnosis swallowing and vomitting problems
250972 - caused by achalasia, ref SDS 13 MD4N, patient meets criteria for
250973 - treatment with pneumatic dilation. ref SDS 13 MD5G
250975 - ..
250976 - On 060505 Martinez VA GI clinic Doctor Lee reported equipment and
250977 - pneumatic balloon materials on hand to perform dilation for treating
250978 - achalasia; treatment delayed until diagnostic data is received from
250979 - Sacramento VA Medical Center from manometry test performed on 060330;
250980 - doctor following up to obtain data; will submit test data to patient
250981 - during the week of 060508, along with a schedule to treat achalasia.
250982 - ref SDS 14 FT6M
250984 - ..
250985 - On 060614 Martinez VA GI clinic reports increased work load treating
250986 - soldiers returning from war in Iraq requires prioritizing; patient
250987 - advocate, Rubin Soto, will coordinate with the GI Clinic notifying the
250988 - customer of the schedule based on current priorities. ref SDS 15 J86N
250990 - ..
250991 - On 070220 letter to VA asks about progress getting test results from
250992 - VA in Sacramento, and scheduling surgery for achalasia, ref SDS 16
250993 - 5R5R
250995 - ..
250996 - On 090812 1030 continued vomitting achalasia causes weight loss 30
250997 - pounds in a few months, Primary Care physician notified GI clinic to
250998 - review schedule for dilation to relieve achalasia. ref SDS 17 7L5O
251000 - ..
251001 - On 090908 meeting GI Clinic in Martinez reports treatment for
251002 - achalasia still waiting to receive results for manometry test on
251003 - 060330, at Sacramento VA Medical Center. ref SDS 18 HX46 Prepared new
251004 - work plan to treat achalasia without manometry test results, because
251005 - the doctor performed the test 3 years ago, and is so knows results
251006 - consistent with achalasia, shown on 060330 0712, ref SDS 13 MD4N;
251007 - schedules treatment for achalasia after treadmill stress test,
251008 - ref SDS 18 BU6W, to evaluate new chest pains hiking hills at Lafayette
251009 - Reservoir which have not occurred doing extended exercise hiking 3 -
251010 - 14 miles a day over the past 5 years. ref SDS 18 MY4N
251012 - ..
251013 - On 091021 report history achalasia issue during meeting with
251014 - cardiothoracic surgery team to prepare for heart bypass surgery the
251015 - next day. ref SDS 20 NX6M Surgery team will coordinate with
251016 - anesthesia team to provide swallowing relief during heart surgery to
251017 - prevent choking. ref SDS 20 R78O
251019 - ..
251020 - On 091022 0700 meeting anesthesia team - Doctor Brezinski not familiar
251021 - with achalasia - asked if achalasia has been reported to the VA?
251022 - ref SDS 21 JF9K While being prepared with IVs for surgery, patient
251023 - assists anesthesia find VA records on achalasia, ref SDS 21 2W4K;
251024 - Doctor Brezenski makes plans for patient care and safety so that
251025 - achalasia does not risk death during heart surgery. ref SDS 21 GX4J
251027 - ..
251028 - On 091022 cabg x4 cardiothoracic surgery San Francisco Medical Center.
251029 - ref SDS 21 PQWU
251031 - ..
251032 - On 091030 0800 at 1406 meeting with Doctor Stewart at San Francisco
251033 - Medical Center during recovery from heart surgery, proposes Heller
251034 - Myotomy surgery rather than pneumatic (balloon) dilation as more
251035 - effective and longer lasting solution to recover from swallowing and
251036 - vomitting problems caused by achalasia. ref SDS 24 KE3B
251038 - ..
251039 - On 091030 0800 at 1430 received documentation from GI Department at
251040 - San Francisco Medical Center - review shows 3 different treatments for
251041 - achalasia - pills, pneumatic dilation, Heller Myotomy surgery.
251042 - ref SDS 24 495I
251044 - ..
251045 - On 091030 0800 at 1440 meeting cardiothoracic surgery team; Doctor
251046 - Ratcliff concerned about how to maintain nutrition for the patient to
251047 - recover from heart surgery while digestion remains problematic due to
251048 - achalasia; proposes feeding tube for several months until Heller
251049 - Myotomy surgery. ref SDS 24 03GF
251051 - ..
251052 - On 091216 Heller Myotomy surgery at San Francisco VA Medical Center to
251053 - recover from achalasia. 091216 0600, ref SDS 36 KE9U
251055 - ..
251056 - On 100202 meeting with Doctor Lee - report swallowing and vomitting
251057 - problems 3 months after Heller Myotomy surgery. Doctor explains
251058 - achalasia disease breaks nerve connections from the brain that
251059 - contract the esophagus to force food and liquid from the mouth through
251060 - the esophagus; as well broken nerve connections prevent the lower
251061 - esophageal sphincter valve (LESV) to relax so that content can pass
251062 - into the stomach. Without esophageal contractions, food and liquid
251063 - can only reach the stomach with gravity, but since the LESV won't
251064 - relax the patient continues to have swallowing and vomitting problems,
251065 - despite Heller Myotomy surgery on 091216, intended to maintain
251066 - adequate opening into the stomach. ref SDS 47 485W
251068 - ..
251069 - On 100305 meeting at GI Clinic in Martinez, EGD procedure dilated LESV
251070 - from 11 to 15 mm. ref SDS 48 WR6L
251072 - ..
251073 - On 100827 meeting at GI Clinic in Martinez, EGD procedure dilated LESV
251074 - from 11 to 15 mm. ref SDS 55 JE6X
251076 - ..
251077 - On 101210 EGD procedure dilated esophageal sphincter valve (LESV)
251078 - without sedation, ref SDS 67 BE7K - dilated LESV again from 11 to 14
251079 - mm. ref SDS 67 BF6L
251081 - ..
251082 - On 101216 1021 letter commends medical team for excellent work, and
251083 - confirms schedule next EGD on 110218 0730. ref SDS 69 K35G
251085 - ..
251086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using
251087 - anesthesia with Fentanyl. ref SDS 72 PQWY LESV dilated 11 - 14 mm,
251088 - and added triamcinolone steriod injections to resist contraction of
251089 - LESV so that swallowing is maintained over the next 3 month cycle.
251090 - ref SDS 72 SR4G
251092 - ..
251093 - On 110429 0830 5th EGD dilation at VA in Martinez - triamcinolone
251094 - steriod injections worked well to resist contraction of LESV so that
251095 - swallowing was maintained over the prior 3 month cycle, ref SDS 76
251096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 76 U23I, and
251097 - triamcinolone injections were continued. ref SDS 76 SS5N
251099 - ..
251100 - On 110607 1414 visited GI Department, ref SDS 78 HC5H, and Charlene
251101 - reported a computer mistakes requires scheduling next EGD dilation on
251102 - 110819 0830. ref SDS 78 N642 Requested meeting with Doctor Lee to
251103 - review pending action items. ref SDS 78 4P6J,
251105 - ..
251106 - On 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter
251107 - valve. Triamcinolone steriod injections worked well to resist
251108 - contraction of LESV so that swallowing is maintained over the prior 3
251109 - month cycle, so LESV dilated from 15 - 16.5 mm, ref SDS 81 J978, and
251110 - triamcinolone injections were continued. ref SDS 81 J985
251112 - ..
251113 - On 111115 1300 EGD dilation procedure - triamcinolone steriod injections
251114 - worked well over the prior 3 month cycle, so LESV dilated from 16.5 -
251115 - 18 mm, ref SDS 82 IR57; for some reason triamcinolone injections to
251116 - resist contraction of LESV was not performed. ref SDS 82 IS6L
251118 - ..
251119 - On 120322 1030 EGD dilation procedure - swallowing and vomitting problems
251120 - increased without triamcinolone steriod injections on prior 3 month
251121 - cycle. ref SDS 84 UI9H LESV dilated from 16.5 - 18 mm. ref SDS 84
251122 - 516N Triamcinolone injections to resist contraction of LESV was not
251123 - performed. ref SDS 84 5179
251125 - ..
251126 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA
251127 - business unit; reported patient history. ref SDS 87 RG9K Scheduled
251128 - EGD and dilation procedure for 1300; returned and performed procedure,
251129 - ref SDS 87 TB4J; dilated from 15 mm to 18 mm. ref SDS 87 XB51
251130 - Swallowing and vomitting problems increased after omitting
251131 - triamcinolone steriod injections to resist contraction of LESV after
251132 - dilation, ref SDS 87 TZ4M; therefore, injections were resumed to
251133 - complement dilation to enable and maintain effective swallowing.
251134 - ref SDS 87 R87N
251136 - ..
251137 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found
251138 - improvement recovering from acalasia, LESV contracted only slightly
251139 - from 18 mm down to 15 mm. ref SDS 95 Q333
251141 - ..
251142 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV
251143 - remained at 18 MM, ref SDS A0 CO5N, same as dialated 4 months earlier
251144 - on 130110 0900. ref SDS 95 Q333 Report CT test on 130117, shows
251145 - esophagus fully recovered from severe distortions caused by achalasia
251146 - 8 years earlier. ref SDS A0 MT6F Doctor Lee injected steriod again to
251147 - maintain swallowing. ref SDS A0 F38G Prescribed reducing Omeprazole
251148 - to 1 pill per day. ref SDS A0 R74M Scheduled next EDG dilation in 6
251149 - months, instead of 3. ref SDS A0 6P6G
251151 - ..
251152 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5
251153 - to 18 mm. ref SDS A6 CO5N Triamcinolone steriod injected again to
251154 - maintain improved swallowing. ref SDS A6 I167 Omeprazole medication
251155 - maintained 20 mg taken morning and evening for 1 month, then reduce to
251156 - 20 mg once per day. ref SDS A6 R74M Biopsies taken. ref SDS A6 3N8L
251158 - ..
251159 - On 131121 1604 ordered refill of Omeprazole to aid digestion. There
251160 - is 1 refill remaining. ref SDS A7 YS4O
251162 - ..
251163 - On 131205 1443 received order for Omeprazole prescription placed on
251164 - 131121. ref SDS A8 5N3O
251166 - ..
251167 - On 140318 1043 received letter cancelling meeting scheduled for
251168 - EGD/Dilation procedure on 140425 1000, ref SDS B1 935L; a second
251169 - letter scheduled prodedure on 140509 0900. ref SDS B1 5D7H
251171 - ..
251172 - On 140401 1659 ordered refill Omeprazole; none are remaining; need
251173 - Doctor Lee to order new prescription to increase refills. ref SDS B2
251174 - 4P5M
251176 - ..
251177 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical
251178 - center in Sacramento, Mather. ref SDS B4 K37G Pre-op preperation went
251179 - well - IV setup on first stick. ref SDS B4 EP75 Doctor ordered refills
251180 - for Omeprazole. ref SDS B4 AW5O Doctor patient partnership continues
251181 - to progress with doctor reading up on patient history to be prepared
251182 - for effective meeting. ref SDS B4 ZZ6J Doctor Lee recalled today
251183 - having made timely referral for having heart surgery, enabling patient
251184 - to recover and Half Dome 4 years later. ref SDS B4 0N6I Reported
251185 - swallowing and vomitting problems reduced past 6 months with
251186 - triamcinolone steriod injections to resist contraction of LESV.
251187 - ref SDS B4 VV6N Doctor Lee dilated LESV contracted to only 16.5 MM
251188 - over past 6 months with triamcinolone steriod injections to resist
251189 - contraction; he dilated LESV back to 18 MMy, ref SDS B4 5H5J, scheduled
251190 - next EGD dilation in 6 months since this worked well the past 6 months
251191 - with triamcinolone steriod injections. ref SDS B4 549I The doctor
251192 - explained that since there was no tearing of LESV during procedure
251193 - today, triamcinolone steriod was not injected into LESV to resist
251194 - contraction. ref SDS B4 I167 Progress notes report small tearing of
251195 - LESV during dilation procedure. ref SDS B4 P680
251197 - ..
251198 - On 140718 1017 planning for notifying VA to update current fill date
251199 - for Omeprazole. ref SDS B8 U88L Kathy visited VA in Sacramento, and
251200 - requested changing refill date for Omeprazole to 140718. ref SDS B8
251201 - OL5K VA representative called customer, and said Doctor Lee would
251202 - call back later that day to consider action on updating scheduled
251203 - refill date of Omeprazole to 140718. ref SDS B8 U76M
251205 - ..
251206 - On 140810 1839 letter to Doctor Lee requesting EGD dilation with
251207 - triamcinolone injection soonest, if cancellation occurs; but, not an
251208 - emergency, ref SDS C0 W83K, based on history rising vomitting
251209 - swallowing problems, shown in patient history case study on 120101,
251210 - beginning 140712. ref SDS 83 4E4M
251212 - ..
251213 - On 140819 0800 during meeting at VA Primary Care Clinic in Martinez,
251214 - Doctor Sandhu indicated Doctor Lee at VA Medical Center in Sacramento
251215 - will be notified about rising achalasia symptoms for consideration to
251216 - advance EGD dilation procedure. ref SDS C1 EX78
251218 - ..
251219 - On 141014 0943 Kathy visited VA Medical Center in Sacramento and met
251220 - with Lapria again, who advised that the VA responded in a letter on
251221 - 141001, to the letter on 140810, and further scheduled a meeting with
251222 - Doctor Lee on 141121 1530. ref SDS C2 QJ5N
251224 - ..
251225 - On 141103 2152 submitted agenda for meeting with Doctor Lee at VA
251226 - Sacramento Medical Center on 141107 0800, for next EGD dilation.
251227 - ref SDS C3 K37G Submit record showing normal swallowing occurs longer
251228 - with triamcinolone steriod injection to resist contraction of LESV.
251229 - ref SDS C3 3U97 Request schedule next EGD dilation in 4 months, and
251230 - if LESV does not contract, then schedule following EGD dilation in 6
251231 - months. ref SDS C3 3U66 Notified results of Half Dome hike.
251232 - ref SDS C3 3U6Y
251234 - ..
251235 - On 141107 0800 EGD dilation procedure - setting IV for conscious
251236 - sedation required 3 sticks. ref SDS C4 5W5I Meeting Doctor Lee guided
251237 - by agenda facilitated collaboration through doctor patient
251238 - partnership. ref SDS C4 VV6N Doctor explained increased difficulty
251239 - swallowing due to experiment omitting triamcinalone steriod injection
251240 - on prior procedure, ref SDS C4 4U8I, shown by LESV contracting back to
251241 - from 15 mm. ref SDS C4 T55I Progress Notes report finding ulceration
251242 - and hiatal hernia. ref SDS C4 MG6N Photographs seem to show
251243 - significantly different condition of fundoplication from a year
251244 - earlier. ref SDS C4 I74I
251246 - ..
251247 - On 150319 0800 meeting Doctor Lee in GI Clinic VA Medical Center
251248 - Sacramento report swallowing improved with triamcinalone steriod
251249 - injections on 141107 EGD dilation procedure. ref SDS D0 0M6I Doctor
251250 - Lee advised that increased orange juice consumption aids digestion,
251251 - and presents no health risks. ref SDS D0 YF5M Scheduled next EGD
251252 - dilation procedure on 150421 1300. ref SDS D0 PS4O Fundoplication
251253 - failure increases acid burn that caused ulceration with hiatal hernia
251254 - with increased recurrance achalasia. ref SDS D0 O56O Doctor Lee will
251255 - make referral to Doctor Stewart at General Surgery VA Medical Center
251256 - in San Francisco for consideration of "redo" fundaplicaiton.
251257 - ref SDS D0 JQ5J Doctor Lee completed Progress Notes for EGD dilation
251258 - on 141107. ref SDS D0 PS53 Doctor Lee will recommend Doctor Stewart
251259 - order CT test to evaluate recurrance achalasia due to failure
251260 - fundoplication. ref SDS D0 TH5M This test can include coronary CTA to
251261 - evaluate regression atherosclerosis. ref SDS D0 GB56
251263 - ..
251264 - On 150420 1752 submitted letter to Doctor Lee with agenda for meeting
251265 - the next day on 150421 1300 for EGD dilation. ref SDS D2 0M6I
251267 - ..
251268 - On 150421 Met with Doctor Lee at VA Medical Center in Sacramento
251269 - (Mather). ref SDS D3 K37G No difficulties setting IV for conscious
251270 - sedation. ref SDS D3 5W5I Reported pain level 2 right knee MCL.
251271 - ref SDS D3 LO9K Doctor Lee advised referral to San Francisco will be
251272 - filed after EDG dilation procedure (this day) to evaluate loosening
251273 - fundoplication. ref SDS D3 DZ4I Patient reported difficulty
251274 - swallowing this cycle did not occur until 4 weeks or so, because
251275 - triamcinalone steriod was injected during prior procedure on 141107,
251276 - ref SDS D3 P55L, and shown by EGD dilation LESV from 16.5 mm back to
251277 - 18 mm. ref SDS D3 HU42 Progress Notes report findings of hiatal
251278 - hernia. ref SDS D3 QD6O Impression today that ulceration has subsided
251279 - to mere errosions seems promising. ref SDS D3 PXXY
251281 - ..
251282 - On 150514 0130 letter to Doctor Lee requests file Progress Notes for
251283 - EGD Dilation today, and make referral to Doctor Stewart, to prepare
251284 - for meeting with Doctor Lee scheduled on 150521. ref SDS D5 K37G
251286 - ..
251287 - On 150521 0800 meeting with Doctor Lee at VAMC in Sacramento -
251288 - concensus uncharacteristic vomitting after recent EGD dilation
251289 - procedure on 150421, due to patient not eating slowly with small bites
251290 - and drinking liquids frequently, especially when eating meat products
251291 - that have high viscocity with esophageal tissue, and so tends to
251292 - stick, causing vomitting. ref SDS D7 WT9L
251294 - ..
251295 - On 150526 1300 meeting with Doctor Stewart Chief General Surgery VA
251296 - Medical Center San Francisco, review record indicating ulceration LESV
251297 - caused by reflux backwash into esophagus. ref SDS D8 3E4I Doctor
251298 - Stewart explained redo Dor Fundoplication required for "repairing"
251299 - original surgery, presents high risk of collateral damage. ref SDS D8
251300 - GT5G Considered increase dose Omeprazole (PPI) since ad hoc
251301 - experience occasionally taking 3 and sometimes 4 pills instead of only
251302 - 1 pill per day seemed to reduce reflux based on examination showing
251303 - ulceration of LESV declined; this would avoid need to redo Dor
251304 - Fundoplication. ref SDS D8 5Y4I
251306 - ..
251307 - On 150616 1624 received photographs on CD in word.docx file from
251308 - Phillip in ROI Department at VA MC in Sacramento (Mather) showing Dor
251309 - fundoplication in tact on 131115, beginning to unravel on 140507,
251310 - further unraveled on 141107, and unraveled on 150421. ref SDS E1 XW6M
251312 - ..
251313 - On 150623 1300 during follow up meeting, Doctor Stewart discussed
251314 - again increasing Omeprazole PPI to resolve ulceration of LESV rather
251315 - than risk difficult surgery to redo Dor fundoplication, and she
251316 - ordered prescription for H2 blocker to supplement Omeprazole PPI.
251317 - ref SDS E2 WW5K
251319 - ..
251320 - On 150624 0924 letter notified Doctor Lee of work plan to try
251321 - controlling ulceration of LESV by increasing PPI with Omeprazole
251322 - rather than chance performing high risk surgery to repair Dor
251323 - fundoplication, and that Doctor Stewart ordered H2 Blocker for Doctor
251324 - Lee to consider supplementing PPI to control acid reflux. ref SDS E3
251325 - OP91
251327 - ..
251328 - On 150624 0924 at 1344 Doctor Lee called and will order new
251329 - prescription for PPI increasing Omeprazole from 20 mg twice per day to
251330 - 40 mg twice per day. ref SDS E3 L861
251332 - ..
251333 - On 150925 0336 request switch back to Omeprazole 20 mg twice per day
251334 - in order to reduce severe side effects of dehydration from frequent
251335 - urination causing scaling, peeling, bleeding feet; lower dose
251336 - Omeprazole enables hiking to raise HDL required to regress
251337 - atherosclerosis plaques, thereby lowering risks of CVD and CAD.
251338 - ref SDS E5 5G8T As a result, Pharmacy VA Medical Center San Francisco
251339 - entered new prescription for (PPI) Omeprazole 20 mg. ref SDS E5 FK66
251341 - ..
251342 - On 150925 0336 VA scheduled next meeting for EGD dilation on 151204
251343 - 0800. ref SDS E5 SR6L
251345 - ..
251346 - On 151002 1820 Doctor Lee returned call; will order Omeprazole 20 mg
251347 - prescription sufficient until next EGD Dilation procedure on 151204,
251348 - and complimenting prescription entered on 150925 for only 1 month.
251349 - ref SDS E6 NV5I
251351 - ..
251352 - On 151012 1151 VA Internet Pharmacy lists updated Omeprazole 20 mg
251353 - prescription. ref SDS D4 0C5H
251355 - ..
251356 - On 151204 0800 met with Doctor Lee at VA Medical Center in Sacramento
251357 - (Mather); initial administration went well. ref SDS 0 GD4H
251358 - Preparation for the procedure was professional; no difficulties
251359 - setting IV for conscious sedation today. ref SDS 0 544G The doctor
251360 - reported not receiving letter with agenda for the meeting today,
251361 - submitted on 151201. ref SDS 0 VV6N Patient difficulty swallowing
251362 - occurred after 5 months, because triamcinalone steriod injected prior
251363 - procedure on 150421. Swallowing difficulty/vomiting increased over
251364 - the next 3 months indicates dilate LESV 18 mm and doing EGD dilation
251365 - in 6 rather than 8 months. ref SDS 0 P55L Asked about Baking Soda to
251366 - clear throat in order to avoid vomitting, and prevent ulceration LESV
251367 - alternative to Omeprazole in order to avoid side effects causing
251368 - dehydration. ref SDS 0 G53K Performing EGD dilation procedure went
251369 - smoothly, with no difficulties. ref SDS 0 7V6I Post procedure Doctor
251370 - Lee reported LESV contracted to 10 mm, the worst results in patient
251371 - history, indicating 2 month delay performing procedure this cycle was
251372 - harmful. ref SDS 0 5H5J
251373 -
251374 -
251375 -
251376 -
251377 -
251378 -
251380 - ..
2514 -
2515 -
2516 - Progress
251701 - ..
251702 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
251703 - GI Department VA Sacramento Medical Center Administration EGD Dilation
251704 -
251705 - Follow up ref SDS D3 NU8L, ref SDS C4 NU8L.
251706 -
251707 - Meeting today implements planning in Progress Notes on 150421 1210.
251708 - ref SDS D3 LG9L, and the record scheduling the specific date today, as
251709 - reported on 150925 0336. ref SDS E5 SR6L
251711 - ..
251712 - Agenda for meeting today, was submitted with letter to Doctor Lee on
251713 - Tuesday, 151201 2111. ref SDS F1 DF5J
251715 - ..
251716 - Applied pre-proc requirements for NPO after midnight, from letter on
251717 - 101015 1547. ref SDS 59 4J9L Last food was at......
251719 - ..
251720 - Stayed in Concord last night. This morning, Kathy drove us to VA
251721 - Medical Center at Mather AFB in Sacrmento.
251723 - ..
251724 - Checked into GI Department at the customer counter. New cast of
251725 - characters, with two young people doing initial check-in...
251726 -
251727 - 800-382-8387
251728 -
251729 - 916 843 7000
251731 - ..
251732 - Kathy cell phone for designated driver...
251736 - ..
251737 - Kathy signed the discharge form affirming she will be designated
251738 - driver, and responsible to facilitate no driving for 24 hours.
251740 - ..
251741 - Nurse at customer counter asked questions on patient history to verify
251742 - ready for procedure, e.g., no allergies, and NPO after midnight to
251743 - avoid conflicts with anesthesia; no health problems, e.g., no
251744 - diabetes, alcohol, cigarettes.
251746 - ..
251747 - Waited in lobby for 3 minutes. Then Jessica called to prepare for
251748 - procedure.
251749 -
251751 - ..
2518 -
2519 -
2520 - 0907
2521 -
252101 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
252102 -
252103 - Follow up ref SDS D3 EP75, ref SDS C4 EP75.
252104 -
252105 - Jessica took vitals today, prior to procedure in a small office just
252106 - off the lobby, and not in the treatment center, reported on 120925
252107 - 0900. ref SDS 87 PT5P
252109 - ..
252110 - Vital included...
252111 -
252112 - Weight.................. 187 (fully dressed, shoes, cell phone)
252113 - BP...................... 123 63
252114 - HR (pulse).............. 54
252115 - Temp.................... 97.8
252117 - ..
252118 - Jessica then led the way into the OR preparation room, and assisted
252119 - with dressing down and laying on a gurney.
252121 - ..
252122 - Laura then took over to perform prepartion work. Configured on gurney
252123 - and connected equipment to monitor vitals during the procedure.
252125 - ..
252126 - Laura set catheter IV for sedation. Required only 1 stick, so better
252127 - day than last time on 141107 0800. ref SDS C4 544G
252129 - ..
252130 - Case study on sticks required to set catheter is reported on 110429
252131 - 1230. ref SDS 76 UO3G
252133 - ..
252134 - Laura went through patient identification and medical profile filling
252135 - out forms on the computer.
252137 - ..
252138 - She asked about pain? Reported level 0.
252140 - ..
252141 - Waited about 15 minutes.
252142 -
252143 -
252144 -
252146 - ..
2522 -
2523 -
2524 - 1320
2525 -
252501 - Consent Signed EGD Dilation and Meeting Review Pending Issues
252502 - Consultation Pending Issues and Sign Consent for EGD Dilation
252503 -
252504 - Follow up ref SDS D3 RG9K, ref SDS C4 RG9K.
252505 -
252506 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation
252507 - procedure today.
252509 - ..
252510 - Noted that signature is entered on completely black screen, required
252511 - without reading online documents.
252512 -
252513 -
252514 -
252516 - ..
252517 - Swallowing Vomitting Difficulties Resolved with Triamcinolone Injections
252518 - Triamcinolone Injection Prevent LESV Contraction Avoid Swallowing Vomitting Problems
252519 -
252520 - Follow up ref SDS D3 VV6N, ref SDS C4 VV6N.
252521 -
252522 - Doctor Lee reported he has not received the letter sent to the VA
252523 - Tuesday evening, on 151201, submitting the agenda for the meeting
252524 - today performing EGD dilation. ref SDS F1 DF5J
252526 - ..
252527 - We can review these pending issues during meeting next week on 151210,
252528 - planned to review results of the meeting today, and scheduled at the
252529 - same time the meeting today was set, reported on 150925 0336.
252530 - ref SDS E5 QR5O
252532 - ..
252533 - Doctor Lee plans to use Triamcinolone steroid injection during the
252534 - procedure today, based on favorable results, and planning during the
252535 - meeting on 150319 0800, ref SDS D0 6P9M, and as applied during prior
252536 - EGD dilation on 150421 1210. ref SDS D3 HU5P
252538 - ..
252539 - Doctor Lee asked about swallowing problems?
252541 - ..
252542 - Advised that swallowing and vomiting are presented in letter with
252543 - agenda submitted 2 days ago on 151201 2111. ref SDS F1 DF5J While we
252544 - talked, the doctor tried to access the letter on the computer in the
252545 - procedure preparation room, and located next to the bed.
252547 - ..
252548 - Past 8 weeks or so saliva tends to build up in the esophagus, and
252549 - vomitting has increased by orders of magnitude, as set out in the
252550 - letter to the doctor submitted this past Tuesday on 151201 2111.
252551 - ref SDS F1 DF5J Therefore would have preferred doing this dilation
252552 - with triamcinolone steriod injections on normal 6 month cycle in
252553 - October, which resists contraction of LESV, so that effective
252554 - swallowing is maintained, as shown in Progress Notes on 111115 300.
252555 - ref SDS 82 AW6J and reported again in Progress Notes on 120925 0900.
252556 - ref SDS 87 E558 The 2 month delay to December caused swallowing and
252557 - vomitting to grow much worse.
252559 - ..
252560 - Estimated LESV will engage today at < 15mm, based on recent severe
252561 - swallowing problems, reported in agenda on 151201 2111. ref SDS F1
252562 - DF5J
252563 -
252564 - [...below on 151204 0800 at 1050 after the procedure Doctor
252565 - Lee reported LESV contracted this cycle to 10 mm from 18,
252566 - and so he could only dilate today back to 15 mm.
252567 - ref SDS 0 5H5J
252568 -
252570 - ..
252571 - Omeprazole Reduce Side Effects Dehydration Baking Soda Treat Reflux
252572 - Baking Soda Treat Reflux Reduce Omeprazole Side Effects Dehydration
252573 - Reflux Baking Soda Treatment Reduce Omeprazole Side Effects Dehydration
252574 -
252575 - Asked about Baking Soda to aid swallowing, and reduce reliance on
252576 - Omeprazole for controlling reflux in order to prevent ulceration LESV,
252577 - presented in the letter yesterday submitting agenda for the meeting
252578 - today. 151201 2111, ref SDS F1 IC5L
252580 - ..
252581 - Would Baking Soda provide alternative proton pump inhibitor (PPI) that
252582 - reduces side effects from taking Omeprazole, cited yesterday on 151203
252583 - 0900? ref SDS F2 OI9L
252585 - ..
252586 - Discussed requirements to reduce reliance on Omeprazole in order to
252587 - reduce adverse side effects that damage liver function, presented in
252588 - the letter submitting the agenda, reported on 151201 2111. ref SDS F1
252589 - IC5L Liver damage is shown in part by chronic elevated bilirubin, and
252590 - symptoms of frequent urination, which causes dehydration that injuries
252591 - feet, thereby preventing hiking. Since hiking has proven to increase
252592 - HDL 30 to HDL 70 - 130%, and since CCTA on 151019, shows this elevated
252593 - HDL has regressed atheroscloerosis, developing alternatives to
252594 - Omeprazole seems important to balance treatments for controlling acid
252595 - reflux and regressing atherosclerosis.
252596 -
252597 - [...below on 151204 0800 at 1050 after EGD dilation
252598 - procedure, Doctor Lee cautioned against Baking Soda,
252599 - because favorable effects reducing chest pain from acid
252600 - reflux lasts for a short time; he prescribed 2 new remedies
252601 - - Rautidine 300 mg and Mylanta 30 ml to solve the problem
252602 - without causing adverse side effects of Omperpazole.
252603 - ref SDS 0 EY9K
252605 - ..
252606 - [...below on 151204 0800 at 1050 side effects taking Baking
252607 - Soda treatment for reflux are listed in this record after
252608 - EGD dilation procedure. ref SDS 0 SG5J
252609 -
252611 - ..
252612 - Signed consent for the procedure, which is not visible - there is
252613 - merely a black screen to sign.
252614 -
252615 -
252616 -
252617 -
252619 - ..
2527 -
2528 -
2529 - 0840
2530 -
253001 - OR EGD Dilation with Application Lidocaine
253002 - EGD Dilation Procedure in OR Application Lidocaine
253003 -
253004 - Follow up ref SDS D3 7V6I, ref SDS C4 7V6I.
253005 -
253006 - Laura wheeled the gurney into the OR for the procedure. Met Christy.
253008 - ..
253009 - Everything went smoothly, as always.
253011 - ..
253012 - Grace applied conscious sedation using the catheter set by Laura in
253013 - Preparation, per above. ref SDS 0 544G
253014 -
253015 - [...below on 150421 1210 Progress Notes report intravenous
253016 - medication applied for conscious sedation. ref SDS D3 P341
253018 - ..
253019 - The team then did the EDG/dilation procedure.
253020 -
253021 -
253022 -
253024 - ..
253025 - Dilated 15 MM Rather than Healthy LESV 20 MM Meeting Doctor Lee
253026 - Meeting Doctor Lee Present Results EGD Dilation Procedure 15 MM
253027 - Results EGD Dilation Procedure Meeting Doctor Lee Present 15 MM
253028 -
253029 - Follow up ref SDS D3 5H5J, ref SDS C4 5H5J.
2531 -
2532 -
2533 - 1050
2534 -
253402 - ..
253403 - An hour or so after the procedure, met with Doctor Lee in the recovery
253404 - room. Still groggy from procedure, so had difficulty following
253405 - everything during the meeting - just wanted to leave. Kathy later
253406 - filled in some details.
253408 - ..
253409 - Doctor Lee advised that EGD examination today, found LESV contracted 8
253410 - mm from 18 mm down to 10 mm, since prior dilation 8 months ago on
253411 - 150421 1210, ref SDS D3 5H5J, and following up discussion this morning
253412 - prior to the procedure, per above. ref SDS 0 MQ4M LESV contraction to
253413 - 10 mm is the worse condition in patient history, shown in case study
253414 - below. ref SDS 0 I167 Significant worsening of LESV contraction to 10
253415 - mm reflects 2 months delay performing EGD compared to patient history
253416 - (see "Months Interval" below, ref SDS 0 YG1J), and aligns with severe
253417 - swallowing problems shown by increased vomiting, reported prior to the
253418 - procedure, per above. ref SDS 0 P55L
253420 - ..
253421 - The doctor presented photographs showing a seemingly large food item
253422 - was still in the esophagus that would not pass through the extremely
253423 - constricted LESV opening into the stomach.
253425 - ..
253426 - This is the first time in patient history when the esophagus became so
253427 - tightly closed that all food would not disolve enough to seep through
253428 - LESV over the 12 hours since the last time solid food was eaten, in
253429 - this case yesterday on 151203 at 1700, shown in case study, 140101
253430 - 0600. ref SDS A9 S75O
253432 - ..
253433 - [On 140101 0600 case study reporting results on 151204,
253434 - vomiting 0% after dilating LESV to only 15 mm instead of 18
253435 - mm. ref SDS A9 XSVR
253437 - ..
253438 - [On 140101 0600 case study reporting on 151206, no further
253439 - vomiting episodes since EDG dilation to 15 mm on 151204.
253440 - ref SDS A9 XSXY
253442 - ..
253443 - Doctor Lee advised that triamcinolone steriod was injected again
253444 - today, in order to restore and maintain improved swallowing for the
253445 - next 6 months, as it has the past 2 years, since 120925...
253446 -
253447 - L E S V D I A L A T I O N H I S T O R Y
253448 -
253449 - Months from -- to
253450 - Interval Date mm mm
253451 - 8 151204 10 15.....triamcinolone.... ref SDS 0 6P6G
253452 - 6 150421 16.5 18.....triamcinolone.... ref SDS D3 HU42
253453 - 6 141107 15 18.....triamcinolone.... ref SDS C4 I167
253454 - 6 140509 16.5 18...................... ref SDS B4 P680
253455 - 7 131115 16.5 18.....triamcinolone.... ref SDS A6 RZ45
253456 - 3 130416 18 18.....triamcinolone.... ref SDS A0 Y850
253457 - 4 130110 15 18.....triamcinolone.... ref SDS 95 Q333
253458 - 6 120925 15 18.....triamcinolone.... ref SDS 87 XB51
253459 - 4 120322 16.5 18...................... ref SDS 84 516N
253460 - 3 111115 16.5 18...................... ref SDS 82 IR57
253461 - 4 110819 15 16.5...triamcinolone.... ref SDS 81 J978
253462 - 3 110429 13 16.5...triamcinolone.... ref SDS 76 U23I
253463 - 3 110218 11 14.....triamcinolone.... ref SDS 72 AA5O
253464 - 4 101210 11 14...................... ref SDS 67 H347
253465 - 5 100827 11 15...................... ref SDS 55 JE6X
253466 - 3 100305 11 15...................... ref SDS 48 WR6L
253467 - 091216 Heller Myotomy Fundoplication ref SDS 36 KE9U
253469 - ..
253470 - Background on triamcinolone injection is further reviewed in the
253471 - record for the meeting at the VA on 140509 0900. ref SDS B4 R26H
253472 -
253473 - [On 160208 1031 called VAMCSAC talked to Jessica; she
253474 - scheduled next EGD dilation on 160315 0900, ref SDS G3
253475 - VB9P; and scheduled next consult on 160405 0930.
253476 - ref SDS G3 VB96
253477 -
253479 - ..
253480 - Ulceration LESV Increased
253481 -
253482 - Doctor Lee reported increased ulceration LESV from prior examination
253483 - on 150421 1210. ref SDS D3 QQ7N This aligns with pausing Omeprazole
253484 - to prevent debilitating side effects from 150819, shown in case study
253485 - on 140101, 140101 0600, ref SDS A9 4Q5F, and then continuing only
253486 - sporadically taking 20 mg only when absolutely necessary every 2 - 4
253487 - days to resolve severe stomach edema, until resuming regularly taking
253488 - Omeprazole 10 mg once per day, beginning on 151021. ref SDS A9 KG5O
253490 - ..
253491 - [...below on 151204 0800 Progress Notes found ulcerations
253492 - on LESV increased. ref SDS 0 PXXY
253494 - ..
253495 - [On 160315 0900 after next EGD dilation, Doctor Lee
253496 - reported finding reduced ulceration taking new medication
253497 - regimen. ref SDS G4 RZ3G
253499 - ..
253500 - This aligns with increasing Omeprazole on adhoc basis to reduce
253501 - episodic effects of reflux, see case study on 140101...
253502 -
253503 - 150205........... ref SDS A9 ER7K
253504 - 150213........... ref SDS A9 2Z7I
253505 - 150214........... ref SDS A9 2Z7I
253506 - 150220........... ref SDS A9 OC6K
253507 - 150307........... ref SDS A9 773J
253508 - 150308........... ref SDS A9 6F5H
253509 - 150418........... ref SDS A9 V64N
253510 -
253512 - ..
253513 - Baking Soda Reflux Short Duration Try H2 Blocker Ranitidine Mylanta
253514 - Ranitidine H2 Blocker Mylanta Instead of Baking Soda Reflux Short Duration
253515 - H2 Blocker Ranitidine Mylanta Instead of Baking Soda Reflux Short Duration
253516 - Mylanta H2 Blocker Ranitidine Instead of Baking Soda Reflux Short Duration
253517 -
253518 - Doctor Lee cautioned against taking Baking Soda to relieve reflux,
253519 - discussed earlier this morning during prep, above. ref SDS 0 G53K He
253520 - indicated there is positive response to this treatment, but it lasts
253521 - only a short time. He further explained that Baking Soda has a high
253522 - concentration of sodium, which is not recommended for patients
253523 - diagnosed with cardiovascular disease (CVD/CAD), and noted patient was
253524 - treated with CABG x4 surgery on 091022 0700. ref SDS 21 PQWU
253525 -
253526 - [On 160315 0900 Doctor Lee's Progress Notes report patient
253527 - taking sodium bicardonate (Baking Soda), and there is no
253528 - longer any associated erosive esophagitis and there is no
253529 - evidence of mass effect. This implies better acid
253530 - suppression compared to the previous examination of
253531 - December 2015. The patient's symptoms of breakthrough for
253532 - which he has been using sodium bicarbonate does indicate an
253533 - area for improvement. ref SDS G5 PXXY
253535 - ..
253536 - Baking soda to treat acid reflux is reviewed on the Internet at...
253537 -
253538 - Healthline
253539 -
253540 - Is Baking Soda the Answer to Acid Reflux?
253541 -
253542 - http://www.healthline.com/health/gerd/baking-soda#Overview1
253544 - ..
253545 - Acid reflux is a common ailment that can be treated with many
253546 - approaches. Sometimes referred to as gastroesophageal reflux
253547 - disease (GERD), it is classified as a type of chronic, or
253548 - ongoing, digestive condition. According to the Mayo Clinic,
253549 - GERD is diagnosed when you have acid reflux symptoms more than
253550 - twice a week.
253552 - ..
253553 - Baking soda ... treatment for acid reflux lies in the
253554 - ingredient sodium bicarbonate. This ingredient... neutralize
253555 - stomach acid and control symptoms of GERD after eating. ...
253556 - pancreas naturally produces sodium bicarbonate to ...
253557 - neutralize stomach acid. Baking soda is thought to mimic the
253558 - same effects as natural sodium bicarbonate production in the
253559 - body.
253561 - ..
253562 - Sodium bicarbonate is also available in some medications with
253563 - omeprazole, a type of proton pump inhibitor.
253565 - ..
253566 - According to the Mayo Clinic, the proper dose of sodium
253567 - bicarbonate powder for adults is one-half teaspoon every two
253568 - hours. The powder should be mixed into a glass of water.
253570 - ..
253571 - Success with baking soda means that stomach acid is effectively
253572 - neutralized. Over time, you may experience fewer cases of
253573 - heartburn.
253575 - ..
253576 - Potential Risks
253578 - ..
253579 - Despite the neutralizing benefits of baking soda, this method
253580 - isn't appropriate for everyone with acid reflux. Since this
253581 - product contains a form of sodium, you should not use it if
253582 - you're following a low-sodium diet. Baking soda can interact
253583 - with other medications and supplements. It's important to
253584 - discuss this risk with your doctor.
253586 - ..
253587 - Side effects include...
253588 -
253589 - 1. gas
253590 - 2. nausea
253591 - 3. increased thirst
253592 - 4. headache
253593 - 5. abdomonal cramps
253595 - ..
253596 - Serious side effects are also possible. Report the following
253597 - symptoms to your doctor right away:
253598 -
253599 - 1. frequent urination
253600 - 2. loss of appetite and/or unexplained weight loss
253601 - 3. breathing difficulties
253602 - 4. swelling in limbs and feet
253603 - 5. bloddy or tar-like stools
253604 - 6. urine with blood
253605 - 7. vomit that looks like coffee grounds
253607 - ..
253608 - So far none of these symptoms have occurred. Since sodium bicarbonate
253609 - is common to Baking Soda and Omeprazole, and since Omeprazole is
253610 - causing frequent urination, taking Baking Soda for alternate relief,
253611 - may not be effective for reducing side effects of Omeprazoe.
253613 - ..
253614 - Instead of Baking Soda, Doctor Lee prescribed new medications to
253615 - reduce reliance on Omeprazole, and in order to reduce severe side
253616 - effects of dehydration.
253618 - ..
253619 - New prescription to try over next week...
253620 -
253621 - 1. Omperazole 20 mg - 30 minutes for dinner
253622 -
253623 - 2. Ranitidine 300 mg - at bedtime
253624 -
253625 - 3. Mylanta 30 ml - at bedtime (liquid)
253627 - ..
253628 - Doctor Lee advised that he ordered from the VAMC Sacramento Pharmacy
253629 - enough Ranitidine and Mylanta for the customer to take over the next
253630 - several weeks. He wants to start this regimin today, by getting the
253631 - new medications from the Pharmacy after the meeting. Can report
253632 - initial impressios of response to treatment during the follow up
253633 - meeting next week on 151210. Based on reported results, the doctor
253634 - will implement or adjust medication prescription on 151210.
253636 - ..
253637 - Since continuing Omperazole 20 mg once per day, this may not reduce
253638 - liver damage. Will experiment over next week, and report results
253639 - during meeting next Friday on 151210 0800.
253640 -
253641 - [...below on 151204 0800 at 1247 received medications from
253642 - VAMC Sacramento Pharmacy, showing Mylanta 15 ml, rather
253643 - than 30 ml prescirbed by Doctor Lee. ref SDS 0 UC6N
253645 - ..
253646 - [On 140101 0600 case study reports on 151206 0200 woke up
253647 - with severe chest pain, despite having taken the night
253648 - before OA 2228 Rautidine 300 mg and Mylanta 30 ml
253649 - prescribed; so tried Baking Soda, and this provided
253650 - immediate relief. ref SDS A9 XSXY
253652 - ..
253653 - [On 151208 1943 letter to Doctor Lee submitting agenda for
253654 - meeting on 151210, and reporting conflict between
253655 - prescription for Mylanta 30 ml received from Doctor Lee on
253656 - 151204, and instructions on the bottle of Mylanta saying to
253657 - take 15 ml. ref SDS F4 RN37
253659 - ..
253660 - [On 151210 0800 follow up meeting Doctor Lee ordered 4
253661 - bottles for enough Mylanta to last until next EGD dilation
253662 - meeting in 4 months OA 160304, ref SDS F5 OD6O; and he
253663 - changed prescription from Ranitidine to Famotidine because
253664 - they do the same thing, but Famotidine pills are smaller
253665 - and so easier to swallow, he ordered 4 month supply.
253666 - ref SDS F5 YL3M
253667 -
253668 -
253669 -
253671 - ..
253672 - Next Meeting 4 Months Decreased from 6 Months Due to Severe Symptoms
253673 -
253674 - The doctor advised that he prescribed next EGD Dilation in 4 months,
253675 - in order to prevent severe contraction of LESV to 10 mm, that occurred
253676 - over the past 8 months causing severe vomiting, and leading to
253677 - dilation to only 15 mm, rather than standard of care dilating to 18
253678 - mm, per above. ref SDS 0 6P6G
253679 -
253680 - [On 160208 1031 called VAMCSAC talked to Jessica; she
253681 - scheduled next EGD dilation on 160315 0900, ref SDS G3
253682 - VB9P; and scheduled next consult on 160405 0930.
253683 - ref SDS G3 VB96
253685 - ..
253686 - 4 month interval for next EGD dilation with LESV contraction to 10 mm
253687 - lowest in patient history, aligns with past practice performing EGD
253688 - dilation on 3 - 4 month intervals with LESV below 16 mm, per above.
253689 - ref SDS 0 YG1J
253691 - ..
253692 - After meeting with Doctor Lee, visited Jessica on the way out of the
253693 - clinic.
253695 - ..
253696 - She said to notify her next month on scheduling meeting with Doctor
253697 - Lee in 4 months on 160304 0800. She cannot schedule the meeting
253698 - today, because the VA computer system does not support scheduling for
253699 - the doctor more than 3 months.
253700 -
253701 - [On 151210 0800 following meeting with Doctor Lee to
253702 - clarify and adjust medication protocols, Jessica reminded
253703 - to notify her on 160104 to schedule next EGD dilation in
253704 - March, because VAMC computer in Sacramento will not support
253705 - scheduling meeting with doctors more than 3 months in
253706 - advance. ref SDS F6 KT6M
253708 - ..
253709 - [On 160104 1349 letter to Jessica in GI Clinic to schedule
253710 - next EGD dilation meeting on 160304. ref SDS F9 HU55
253712 - ..
253713 - [On 160106 2131 letter to Doctor Lee confirms planning for
253714 - EGD dilations on 3 month intervals, and schedule next EGD
253715 - dilation OA 160304 0800. ref SDS G1 T257
253717 - ..
253718 - [On 160126 0004 letter notifies Doctor Lee at GI Clinic in
253719 - VA Medical Center at Sacramento Mather Air Force Base, that
253720 - Doctor Stewart in Surgery Clinic requested 2 EGD dilations
253721 - on 3 month intervals to support follow up evaluation for
253722 - surgical solution to achalasia (Dor fundoplication) issue,
253723 - which requires next EGD dilation OA 160304. ref SDS G2 NU8L
253725 - ..
253726 - [On 160208 1031 called VAMCSAC talked to Jessica; she
253727 - scheduled next EGD dilation on 160315 0900, ref SDS G3
253728 - VB9P; and scheduled next consult on 160405 0930.
253729 - ref SDS G3 VB96
253730 -
253731 -
253732 -
253733 -
253735 - ..
2538 -
2539 -
2540 - 1247
2541 -
254101 - Kathy returned from Pharmacy at VA Medical Center in Sacramento.
254102 -
254103 - She brought...
254104 -
254105 - 1. Ranitidine 300 mg - at bedtime
254107 - ..
254108 - Ranitidine is an H2 blocker to supplement Omeprazole for managing
254109 - reflux to prevent ulceration of LESV. It replaces Famotidine, ordered
254110 - by Doctor Stewart during a meeting at the VA Medical Center in San
254111 - Francisco on 150623 1300. ref SDS E2 WW65
254113 - ..
254114 - Ranititine pills are much bigger than Famotidine, so they are more
254115 - difficult to swallow.
254117 - ..
254118 - 2. Mylanta 2 teaspoons (10 ml) - at bedtime (liquid)
254120 - ..
254121 - Medication issued by Pharmacy for Mylanta 15 ml appears conflicting
254122 - with prescription submitted by Doctor Lee of Mylanta 30 ml, per above.
254123 - ref SDS 0 689J
254125 - ..
254126 - These 2 medications, Fanitidine and Mylanta are intended to enable
254127 - reducing reliance on Omeprazole in order to reduce side effects that
254128 - cause frequent urination, causing dehydration, feet injuires that
254129 - prevent hiking.
254130 -
254131 - [On 151208 1943 letter to Doctor Lee submitting agenda for
254132 - meeting on 151210, and reporting conflict between
254133 - prescription for Mylanta 30 ml received from Doctor Lee on
254134 - 151204, and instructions on the bottle of Mylanta saying to
254135 - take 15 ml. ref SDS F4 RN37
254137 - ..
254138 - [On 151210 0800 follow up meeting Doctor Lee ordered 4
254139 - bottles Mylanta for enough to last until next EGD dilation
254140 - meeting in 4 months OA 160304, ref SDS F5 OD6O; and he
254141 - changed prescription from Ranitidine to Famotidine because
254142 - they do the same thing, but Famotidine pills are smaller
254143 - and so easier to swallow, he ordered 4 month supply.
254144 - ref SDS F5 YL3M
254145 -
254146 -
254147 -
254148 -
254149 -
254150 -
2542 -
SUBJECTS
Medical Chart Progress Notes VA EGD Procedure Stricture Lower Esopha
5503 -
550401 - ..
550402 - Release of Information ROI CD Contents Received on 151224
550403 -
550404 - Follow up ref SDS D3 CY7I, ref SDS C4 CY7I.
550406 - ..
550407 - Decided to request records on CD from ROI for this medical encounter
550408 - due to continual difficulties downloading medical records from VA
550409 - website at...
550410 -
550411 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
550412 -
550419 - ..
550420 - On 151219 sent letter to ROI VAMC Sacramento, with attached VA Form
550421 - 10-5345A requesting medical records for this medical encounter.
550422 - ref SDS F8 2E96
550424 - ..
550425 - On 151224 received following medical records on CD and stored in...
550426 -
550427 - F:\05\00003\SM\CC\AGMJ\20151204-080000\WELCH.pdf
550429 - ..
550430 - This file includes numerous reports flowing from EGD Dilation
550431 - procedure on 151204, and follow up meeting a week later on 151210;
550432 - there is no particular order for the records in this file...
550433 -
550434 - 1. LEGACY VISTA BLOOD BANK REPORT
550436 - ..
550437 - The purpose of this entry is unclear.
550438 -
550439 - 2. SURGICAL PATHOLOGY
550441 - ..
550442 - This is biopsy results for EGD dilation procedure on 151204.
550443 -
550444 - 3. PROGRESS NOTES EGD 60111................. ref SDS 0 9N5G
550446 - ..
550447 - This is the main explanation prepared by Doctor Lee for EGD Dilation
550448 - procedure today.
550449 -
550450 - 4. PRE-PROCEDURE NOTE 60302................. ref SDS 0 ZN3M
550452 - ..
550453 - This lists administration and preparation activities for EGD Dilation
550454 - procedure today.
550455 -
550456 - 5. GASTROENTEROLOGY ATTENDING F/U NOTE 60127..... 151210 0800, ref SDS F5 AV8K
550458 - ..
550459 - This is Doctor Lee's Progress Notes for the meeting on 151210, where
550460 - results were reviewed of EGD Dilation procedure on 151204, and work
550461 - plan was developed for home care until the next EGD Dilation in 4
550462 - months, on 160304.
550463 -
550464 - 6. GI DISCHARGE INSTRUCTIONS................. ref SDS 0 U76O
550466 - ..
550467 - This is the VA's letter to itself claiming to represent verbal and
550468 - written instructions discussed with the patient following recovery
550469 - from sedation for EGD Dilation procedure on 151204.
550470 -
550472 - ..
550473 - Progress Notes EGD Dilation Today
550474 -
550475 - Follow up ref SDS D3 CY7I, ref SDS C4 CY7I.
550476 -
550477 - 1. LOCAL TITLE: EGD 60111
550478 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
550479 - DATE OF NOTE: DEC 04, 2015@08:00 ENTRY DATE: DEC 04, 2015@11:19:38
550480 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
550481 - URGENCY: STATUS: COMPLETED
550482 -
550483 - *** EGD 06111 Has ADDENDA ***
550485 - ..
550486 - EGD & dilation 1518702
550487 - distal GERD stricture dilated 10 to 15mm with TTS balloon.
550488 - injected with triamcinalone
550489 -
550490 - /es/Randall E. Lee, MD
550491 - Staff Physican, Gastronenterology
550492 - Signed: 12/04/2015 1120
550494 - ..
550495 - 2. 12/04/2015 ADDENDUM STATUS: COMPLETED
550496 - PATIENT NAME:
550504 - ..
550505 - 3. NAME OF PROCEDURES:
550506 -
550507 - 1. Esophagogastroduodenoscopy.
550508 - 2. Endoscopic biopsy.
550509 - 3. TTS balloon dilation of esophagus.
550510 - 4. Endoscopic triamcinaolone injection
550512 - ..
550513 - 4. ATTENDING PHYSICIAN:
550514 - Randall E. Lee, M.D.
550516 - ..
550517 - 5. INDICATIONS:
550520 -
550521 - 1. 70-year-old man with history of achalasia. In late 2009
550522 - after undergoing coronary artery bypass and graft, he
550523 - underwent laparoscopic myotomy and fundoplication at the
550524 - San Francisco VA. He subsequently developed acid reflux
550525 - complicated by recurrent distal esophageal stricture. His
550526 - last EGD was April 2015 at which time esophageal stricture
550527 - was dilated from 16.5 mm to 18.0 mm. There were also
550528 - several areas of erosion in the distal esophagus at the GE
550529 - junction extending upwards for about 1 cm.
550531 - ..
550532 - 2. He then began reducing his proton pump inhibitor therapy
550533 - due to concurrent interval development of foot discomfort
550534 - and frequent urination. In July, he stopped his
550535 - omeprazole, which had been at 40 mg twice daily with
550536 - significant reduction of foot discomfort. He then
550537 - restarted omeprazole at 20 mg twice daily, but then reduced
550538 - it to 20 mg once daily. In the interim, he has noticed
550539 - interval development of increasing dysphagia to solid food.
550541 - ..
550542 - 3. He was recently seen in followup by Dr Stewart, his
550543 - Thoracic Surgeon at San Francisco VA who recommended
550544 - against attempting a repair of his fundoplication.
550545 -
550547 - ..
550548 - **************************
550549 - **************************
550550 - This is broader patient history on achalasia issue...
550551 -
550552 - 1. 70-year-old man with history of achalasia found with barium
550553 - swallow test on July 14, 2005. ref SDS 2 2I4S Patient
550554 - underwent CABG +4 on October 22, 2009, at the VA Medical
550555 - Center in San Francisco. ref SDS 21 PQWU At that time in
550556 - October 2009, patient lipid profile was HDL 30 - high risk
550557 - for atherosclerosis. On October 30, 2009, Cardiothoracic
550558 - Surgery team ordered medical remedies for achalasia in
550559 - order to improve swallowing for nutrition to enable
550560 - recovery from CABG heart surgery. ref SDS 24 01F9 On
550561 - December 16, 2009, patient underwent laparoscopic Heller
550562 - Myotomy and fundoplication surgery at the San Francisco
550563 - VA, to resolve achalasia.
550565 - ..
550566 - Several months later, patient continued to experience
550567 - restricted swallowing, and so EGD dilation was performed on
550568 - March 5, 2010, at VA GI Clinic in Martinez. Patient was
550569 - then diagnosed with acid reflux complicated by distal
550570 - esophageal stricture and ulceration of LESV. ref SDS 48
550571 - Y65V Expanded, distorted esophagus recurred with frequent
550572 - vomitting caused by food buildup above constricted LESV,
550573 - indicating Heller Myotomy surgery with fundoplication was
550574 - more effective supplemented with interval GI treatments to
550575 - care for patient's chronic achalasia.
550577 - ..
550578 - Since March 5, 2010, patient swallowing has been maintained
550579 - with EGD dilations that expand LESV initially from 11 mm to
550580 - 15 mm. ref SDS 48 WR6L Proton Pump Inhibitor (PPI) using
550581 - Omeprazole 20 mg was prescirbed to control acid reflux,
550582 - reported during next EGD dilation procedure on August 27,
550583 - 2010. ref SDS 55 JE7X
550585 - ..
550586 - EGD dilation procedure on August 27, 2010, found rising
550587 - ulceration of LESV stricture increased swallowing/vomiting
550588 - problems. ref SDS 55 JF4Q Omeprazole PPI was doubled to 40
550589 - mg. ref SDS 55 MZ8J
550591 - ..
550592 - At next EGD dilation procedure 4 months later on December
550593 - 10, 2010, PPI Omeprazole 80 mg was prescribed to again
550594 - double PPI. ref SDS 67 5I5H
550596 - ..
550597 - On December 19, 2010 patient suffered rising symptoms of
550598 - frequent urination causing dehydration, peeling, cracking,
550599 - bleeding feet correlates with known side effects of
550600 - Omeprazole, ref SDS 70 BE9T, and referencing patient case
550601 - study dated October 10, 2010. ref SDS 57 11Y4 Patient
550602 - tolerated side effects for about a year while receiving EGD
550603 - dilation care on 4 month intervals to maintain swallowing.
550605 - ..
550606 - On February 18, 2011, EGD dilation added triamcinalone,
550607 - steriod injection to LESV. ref SDS 72 AA5O This reduced
550608 - interval constriction of LESV which eventually enabled
550609 - dialating LESV to 18 mm, the maximum prescribed for this
550610 - protocol, and further extended interval to 6 months between
550611 - procedures, reported on November 15, 2011. ref SDS 82 IR57
550613 - ..
550614 - On December 1, 2011, patient paused Omeprazole 80 mg on
550615 - experiencing sudden rise from low to high blood pressure,
550616 - reported in case study on 10 October 2010. ref SDS 57 734L
550617 - Patient resumed Omeprazole 20 mg reduced from 80 mg, 3 days
550618 - later on December 4, 2011. ref SDS 57 ZU8M
550620 - ..
550621 - Patient history maintaining LESV below 15 mm required EGD
550622 - dilations on 4 month intervals; adding injections of
550623 - triamcinalone steriods maintained LESV above 16 mm that
550624 - enabled extending intervals between EGD Dilation procedures
550625 - to 6 months...
550627 - ..
550628 - L E S V D I A L A T I O N
550629 - Months from - to
550630 - Interval Date mm mm
550631 - 8 151204 10 15.....triamcinolone..5.0mL... ref SDS 0 HU42
550632 - 6 150421 16.5 18.....triamcinolone..3.0mL... ref SDS D3 HU42
550633 - 6 141107 15 18.....triamcinolone..4.0mL... ref SDS C4 I167
550634 - 6 140509 16.5 18............................ ref SDS B4 P680
550635 - 7 131115 16.5 18.....triamcinolone..2.0mL... ref SDS A6 RZ45
550636 - 3 130416 18 18.....triamcinolone..2.0mL... ref SDS A0 Y850
550637 - 4 130110 15 18.....triamcinolone..3.0mL... ref SDS 95 Q333
550638 - 6 120925 15 18.....triamcinolone..4.0mL... ref SDS 87 XB51
550639 - 4 120322 16.5 18............................ ref SDS 84 516N
550640 - 3 111115 16.5 18............................ ref SDS 82 IR57
550641 - 4 110819 15 16.5...triamcinolone..2.5mL... ref SDS 81 J978
550642 - 3 110429 13 16.5...triamcinolone..3.5mL... ref SDS 76 U23I
550643 - 3 110218 11 14.....triamcinolone..2.0mL... ref SDS 72 AA5O
550644 - 4 101210 11 14............................ ref SDS 67 H347
550645 - 5 100827 11 15............................ ref SDS 55 JE6X
550646 - 3 100305 11 15............................ ref SDS 48 WR6L
550647 - 091216 Heller Myotomy Fundoplication...... ref SDS 36 KE9U
550649 - ..
550650 - On January 17, 2013, barium swallow CT test showed
550651 - esophagous had fully recovered with no expanded distortion.
550652 - ref SDS 96 OH6G
550654 - ..
550655 - During 2013, patient increased hiking to over 300 miles per
550656 - month to regress atherosclerosis by raising HDL. Increased
550657 - conditioning enabled hiking to the top of Half Dome in
550658 - Yosemite on September 18, 2013.
550660 - ..
550661 - In February 3, 2014, patient lipid profile tested at VA
550662 - Medical Center in San Francisco, improved to HDL 58.
550663 - ref SDS B0 5C7M Four (4) months later on May 14, 2014,
550664 - this increased to HDL 67. ref SDS B5 5C7M With continued
550665 - hiking 300 miles per month, on February 9, lipid profile
550666 - further improved to HDL 70. ref SDS C9 5C7M Patient
550667 - requested VAMCSF perform Coronary CT Angiography (CCTA)
550668 - radiology test to evaluate regression of atherosclerotic
550669 - plaques on theory that HDL above 60 causes rapid regression
550670 - of plaques.
550672 - ..
550673 - On March 19, 2015 patient requested referral to Doctor
550674 - Stewart in General Surgery at VA Medical Center in San
550675 - Francisco, to review rising ulceration of LESV caused by
550676 - reflux, ref SDS D0 JQ5J, and possible surgical remedies
550677 - redoing fundoplication to control reflux, originally
550678 - performed with Heller Myotomy surgery by Doctor Stewart on
550679 - December 16, 2009.
550681 - ..
550682 - Patient's last EGD dilation procedure was on April 21,
550683 - 2015, at which time esophageal stricture was dilated from
550684 - 16.5 mm to 18 mm. There were also several areas of erosion
550685 - in the distal esophagus at the GE junction (LESV) extending
550686 - for about 1 cm.
550688 - ..
550689 - On April 27, 2015, feet injuries prevented hiking, due to
550690 - dehydration while taking statin drugs that cause frequent
550691 - urination. Patient paused statin treatments, and continued
550692 - taking Omeprazole 20 mg. Pausing statins for 3 weeks,
550693 - resolved frequent urination. Dehydration subsided with
550694 - consequent recovery of feet injuries, enabling statin
550695 - treatment to resume on May 16, 2015. ref SDS A9 P84G
550697 - ..
550698 - On May 26, 2015, Doctor Stewart reported high risks for
550699 - redo Dor fundoplicaton, ref SDS D8 093H; she ordered follow
550700 - up barium swallow test, and gastric emptying test.
550701 - ref SDS D8 MF8H
550703 - ..
550704 - On May 27, 2015 barium swallow test showed esophagus was
550705 - still normalized without swelling nor distortion.
550706 - ref SDS D9 TV5O This indicated continuing favorable
550707 - results found in prior barium swallow test on January 17,
550708 - 2013, thereby validating achalasia GI treatment protocol.
550710 - ..
550711 - On June 10, 2015 Eurekalert online scientific journal
550712 - published article titled "Heart attack risk increases 16-21
550713 - percent with use of common antacid." The article reported
550714 - medical study saying in part ..."PPIs can adverseley affect
550715 - the endothelium... lining of the blood vessels," citing
550716 - Omeprazole among common PPI drugs, reported in the
550717 - patient's record on June 11, 2015. ref SDS E0 VC5O Since
550718 - the patient was prescribed to take Omeprazole in 2010, the
550719 - patient notified the GI Clinic in a letter on June 24,
550720 - 2015, asking about risks in this case. ref SDS E3 OP9O
550722 - ..
550723 - On June 23, 2015 Doctor Stewart discussed reducing reliance
550724 - on Omeprazole PPI supplemented with Famotidine H2 Blocker
550725 - to recover from ulceration of LESV by controlling relux,
550726 - rather than attempt surgical redo of fundoplication to
550727 - prevent reflux from causing ulceration of LESV. ref SDS E2
550728 - WW5K
550730 - ..
550731 - The next day on June 24, 2015, patient letter notified the
550732 - VA of increasing Omeprazole back to 80 mg, in order to
550733 - recover from ulceration of LESV by increasing control of
550734 - reflux without changes to fundoplication. Prescription for
550735 - Omeprazole 80 mg was entered on June 24, 2015.
550737 - ..
550738 - On August 9, 2015, while taking Omeprazole 80 mg PPI,
550739 - patient paused prescribed statin treatment to prevent side
550740 - effects of liver damage causing dehydration from frequent
550741 - urination that injured feet with peeling, cracking and
550742 - bleeding. These injuries prevented hiking that raised HDL
550743 - 30 in 2009, to HDL 70 in 2015. The patient believed
550744 - reducing hiking threatened recurrent atherosclerosis, which
550745 - had previously required CABG +4 in 2009, reported in case
550746 - study on 140101. ref SDS A9 GH3G
550748 - ..
550749 - On August 19, 2015, patient paused Omperazle 80 mg PPI,
550750 - because frequent urination did not subside after pausing
550751 - statin treatments, and patient history showed on December
550752 - 19, 2010, frequent urination side effects occurred taking
550753 - Omeprazole 80 mg. ref SDS A9 4Q5F
550755 - ..
550756 - After 4 week pause, on September 18, 2015, patient
550757 - recovered from dehydration side effects of paused
550758 - medication, with feet improved, so hiking could resume.
550759 - ref SDS A9 6L5H
550761 - ..
550762 - Attepmting Half Dome again on September 16, 2015, patient
550763 - suffered injuries from fall. He was treated the next day
550764 - in the ER at VA Medical Center in San Francisco. A week
550765 - later on September 23, 2105, he was admitted into the
550766 - hospital to recover from debridement surgery of large
550767 - hematoma on lower left leg. ref SDS E4 PUTY On October 5,
550768 - 2015 radiology CT study found right wrist fracture.
550769 - ref SDS E7 469H
550771 - ..
550772 - On September 25, 2015, Patient was discharged from VA
550773 - hospital in San Francisco. Prescription for Omeprazole was
550774 - reduced from 80 mg to 20 mg in order to prevent recurrence
550775 - of liver damage with consequent dehydration and feet
550776 - injuries. ref SDS E5 5G8T However, this was only for 1
550777 - month. At that time on September 25th, the GI Clinic at VA
550778 - Medical Center in Sacramento scheduled next GI dilation
550779 - procedure on December 4, 2015.
550781 - ..
550782 - On October 2, 2015, Doctor Lee entered prescription at VA
550783 - Medical Center in Sacramento replacing the 1 month
550784 - prescription and providing Omeprazole 20 mg in sufficient
550785 - amount until the next EGD dilation on December 4.
550787 - ..
550788 - On October 19, 2015, Radiology at Medical Center in San
550789 - Francisco, performed Coronary CT angiography (CCTA). This
550790 - evaluated response to treatment for regressing and
550791 - preventing recurrence of atherosclerosis by hiking 10,000
550792 - miles which increased HDL 30 to HDL 70 over the past 4
550793 - years. Additionally, CCTA hopefully can assess damage to
550794 - endothelial lining of blood vessels reported as side
550795 - effects of Omeprazole PPI. ref SDS E9 T26N Doctor Simpson
550796 - prescribed resuming statin protocol after CCTA test, to
550797 - experiment toward identifying protocol that avoids adverse
550798 - side effects. ref SDS E9 OG3N
550800 - ..
550801 - CCTA on October 19, 2015 found all bypass grafts are
550802 - patent. ref SDS F0 JW8O There is no evidence of
550803 - atherosclerosis plaques, stenosis nor blockage of any kind
550804 - 6 years after CABG +4 on October 22, 2009. CCTA further
550805 - found recurrence of expanded and distorted esophagus,
550806 - indicating significant worsening of patient achalasia
550807 - condition, since barrium swallow test 5 months earlier on
550808 - May 27, 2015. There was no findings on damage to
550809 - endothelial lining of blood vessels.
550811 - ..
550812 - This finding may support reducing statin prescription in
550813 - order to reduce side effects of liver damage causing
550814 - frequent urination. Patient further requests
550815 - consideration to reduce Omeprazole to reduce these side
550816 - effects.
550818 - ..
550819 - Patient is here today, 8 months after prior procedure for
550820 - follow up EGD dilation to restore effective swallowing and
550821 - so reduce food backing up above LESV causing distorted
550822 - esophagus and vomitting. Patient is scheduled to meet in
550823 - GI Clinic on December 10, 2015, to consider adjusting
550824 - Omeprazole treatments that balance controlling acid reflux
550825 - to prevent ulceration of LESV, with avoiding adverse side
550826 - effects of dehydration and damage to endothelium.
550827 -
550828 - **********************************************
550829 - **********************************************
550831 - ..
550832 - 6. CONSENT:
550833 -
550834 - The risks, benefits, and alternatives to this procedure
550835 - including but not limited to the risks of bleeding and bowel
550836 - perforation were explained to the patient. The patient
550837 - understood and provided a written informed consent.
550839 - ..
550840 - 7. INTRAVENOUS MEDICATION:
550841 -
550842 - 1. Diphenhydramine 25 mg.
550843 - 2. Fentanyl 200 mcg.
550844 - 3. Midazolam 5 mg.
550846 - ..
550847 - Why was Diphenhydramine 25 mg reduced from 50 mg used for prior
550848 - procedure on 150421 1210? ref SDS D3 P341
550850 - ..
550851 - Why was Fentanyl 200 mcg decreased from 250 mcg, also used on 150421
550852 - 1210? ref SDS D3 P341
550854 - ..
550855 - Why was Midazolam 5 mg increased from 4 mg used on 150421 1210?
550856 - ref SDS D3 P341
550858 - ..
550859 - Progress Notes EGD Dilation procedure on 151204 continues...
550860 -
550861 - 8. PROCEDURE:
550862 -
550863 - 1. In the Sacramento VA GI Endoscopy Unit, the patient was
550864 - placed in the left lateral decubitus position.
550866 - ..
550867 - 2. Oxygen at 2 liters per minute by nasal cannula was
550868 - administered.
550870 - ..
550871 - 3. Continuous oximetric and hemodynamic monitoring was
550872 - initiated.
550874 - ..
550875 - 4. Intravenous sedation was administered in divided doses.
550877 - ..
550878 - 5. After a bite block was placed in the patient's mouth, an
550879 - Olympus GIF-H180J video gastroscope was advanced under
550880 - direct vision into the esophagus.
550882 - ..
550883 - 6. The lumen of the proximal and mid esophageal body was again
550884 - noted to be dilated and there was a plug of retained food
550885 - obstructing the lumen in the distal esophagus. This was
550886 - easily removed and residual mucos was easily irrigated and
550887 - suctioned away to achieve a good view of the esophagus.
550889 - ..
550890 - Report of food found in esophagus, despite not having eaten for over
550891 - 12 hours, aligns with the doctor's report after the procedure, per
550892 - above. ref SDS 0 HF8L
550894 - ..
550895 - Progress Notes EGD Dilation procedure on 151204 continues...
550896 -
550897 - 7. The gastroscope was then advanced to the distal esophagus
550898 - where an esophageal stricture was identified at about 39
550899 - cm.
550900 -
550901 - 8. The 9.8 mm gastroscope could not be passed through this
550902 - area. A TTS balloon was advanced under direct vision
550903 - through the stricture and inflated sequentially from 10 mm
550904 - to 11 mm to 12 mm. The gastroscope was then advanced
550905 - easily into the esophagus, the balloon was deflated and
550906 - removed.
550908 - ..
550909 - 9. The gastroscope was advanced under direct vision through
550910 - the pylorus and into the third portion of the duodenum.
550912 - ..
550913 - 10. Retroflexed views of the incisura, fundus, and cardia were
550914 - performed.
550916 - ..
550917 - 11. Random biopsies taken from the gastric antrum labeled A and
550918 - from the gastric body labeled B.
550920 - ..
550921 - 12. A second TTS balloon was advanced through the gastroscope
550922 - and positioned across the esophageal stricture. This was
550923 - inflated sequentially from 12-15 mm.
550925 - ..
550926 - 13. The balloon was deflated, removed, and the circumference of
550927 - the esophageal stricture was injected with triamcinolone
550928 - acetate at a concentration of 40 mg/mL for a total volume
550929 - of 5 mL. The stomach was decompressed and the gastroscope
550930 - removed.
550932 - ..
550933 - Case study shows favorable history injecting triamcinolone...
550934 -
550935 - L E S V D I A L A T I O N
550936 - Months from - to
550937 - Interval Date mm mm
550938 - 8 151204 10 15.....triamcinolone..5.0mL... ref SDS 0 HU42
550939 - 6 150421 16.5 18.....triamcinolone..3.0mL... ref SDS D3 HU42
550940 - 6 141107 15 18.....triamcinolone..4.0mL... ref SDS C4 I167
550941 - 6 140509 16.5 18............................ ref SDS B4 P680
550942 - 7 131115 16.5 18.....triamcinolone..2.0mL... ref SDS A6 RZ45
550943 - 3 130416 18 18.....triamcinolone..2.0mL... ref SDS A0 Y850
550944 - 4 130110 15 18.....triamcinolone..3.0mL... ref SDS 95 Q333
550945 - 6 120925 15 18.....triamcinolone..4.0mL... ref SDS 87 XB51
550946 - 4 120322 16.5 18............................ ref SDS 84 516N
550947 - 3 111115 16.5 18............................ ref SDS 82 IR57
550948 - 4 110819 15 16.5...triamcinolone..2.5mL... ref SDS 81 J978
550949 - 3 110429 13 16.5...triamcinolone..3.5mL... ref SDS 76 U23I
550950 - 3 110218 11 14.....triamcinolone..2.0mL... ref SDS 72 AA5O
550951 - 4 101210 11 14............................ ref SDS 67 H347
550952 - 5 100827 11 15............................ ref SDS 55 JE6X
550953 - 3 100305 11 15............................ ref SDS 48 WR6L
550954 - 091216 Heller Myotomy Fundoplication...... ref SDS 36 KE9U
550956 - ..
550957 - [On 151210 0800 follow up meeting Doctor Lee ordered 4
550958 - bottles Mylanta for enough to last until next EGD dilation
550959 - meeting in 3-4 months OA 160304, ref SDS F5 OD6O; and he
550960 - changed prescription from Ranitidine to Famotidine because
550961 - they do the same thing, but Famotidine pills are smaller
550962 - and so easier to swallow, he ordered 4 month supply.
550963 - ref SDS F5 YL3M
550965 - ..
550966 - Progress Notes EGD Dilation procedure on 151204 continues...
550967 -
550968 - 9. COMPLICATIONS:
550969 -
550970 - None immediate.
550972 - ..
550973 - Ulceration LESV and Hiatal Hernia Findings Fundoplication Failed
550974 -
550975 - Follow up ref SDS D3 P396, ref SDS C4 P396.
550976 -
550977 - 10. FINDINGS:
550978 -
550979 - 1. Esophageal stricture again noted beginning at approximately
550980 - 39 cm. Initial diameter was approximately 10 mm. This was
550981 - dilated to 15 mm.
550983 - ..
550984 - This seems worst condition in patient history, shown in above table
550985 - going back to 2010. ref SDS 0 LD8O
550987 - ..
550988 - Progress Notes EGD Dilation procedure on 151204 continues...
550989 -
550990 - 2. Distal esophageal erosion immediately proximal to the
550991 - esophageal stricture.
550993 - ..
550994 - 3. Gastric fundus surgically altered consistent with known
550995 - history of fundoplication.
550997 - ..
550998 - 4. Hiatal hernia clearly visible.
551000 - ..
551001 - Why don't the Progress Notes for work today report fundoplication
551002 - loosening/unravelled based on photographic evidence, and evidence of
551003 - hiatal hernia, and associate this with increased acid reflux causing
551004 - ulceration to LESV? For example...
551006 - ..
551007 - A year ago, on 140509 0900 Progress Notes report hiatal hernia,
551008 - ref SDS B4 P34O; and further state "...hiatal hernia suggests the
551009 - fundoplication appears to be loosening." ref SDS B4 I93F Hiatal
551010 - hernia was also reported 6 months ago on 141107 0800. ref SDS C4 QD6O
551012 - ..
551013 - On 150319 0800 meeting with Doctor Lee indicated fundoplication
551014 - constructed by Doctor Stewart to protect LESV from acid reflux, has
551015 - unraveled, i.e., failed. This caused hiatal hernia. Failure of
551016 - fundoplication also caused ulceration to LESV from increased exposure
551017 - to acid reflux. ref SDS D0 N535; Doctor Lee planned referral to Doctor
551018 - Stewart to assess re-fundoplication or other measures. ref SDS D0 JQ5J
551020 - ..
551021 - Progress Notes EGD Dilation procedure on 151204 continues...
551022 -
551023 - 5. Normal pylorus.
551025 - ..
551026 - 6. Normal duodenum to D2.
551028 - ..
551029 - 11. IMPRESSION:
551030 -
551031 - 1. Gastroesophageal reflux stricture, recurrent with erosive
551032 - esophagitis. This implies need for dilation at 6 month
551033 - intervals in addition to continued acid suppression
551034 - therapy, most prominantly at nightime. There is no
551035 - evidence of malignancy identified.
551036 -
551037 - [On 151210 0800 follow up meeting Doctor Lee ordered 4
551038 - bottles Mylanta for enough to last until next EGD dilation
551039 - meeting in 3-4 months OA 160304, ref SDS F5 OD6O; and he
551040 - changed prescription from Ranitidine to Famotidine because
551041 - they do the same thing, but Famotidine pills are smaller
551042 - and so easier to swallow, he ordered 4 month supply.
551043 - ref SDS F5 YL3M
551045 - ..
551046 - [On 160315 0900 after next EGD dilation, Doctor Lee
551047 - reported finding reduced ulceration taking new
551048 - medication regimen. ref SDS G4 PXXY
551050 - ..
551051 - There was understanding after the procedure that since LESV contracted
551052 - to 10 mm, the worst condition in patient history, and since esophagus
551053 - has again become distored, expanded, then EGD dilation will occur on 3
551054 - - 4 month intervals, as done previously, until LESV recovers
551055 - sufficiently for dilating to 18 mm following former successful
551056 - practice dilating beginning on 100305, 3 months after Heller Myotomy
551057 - surgery with LESV 11 mm...
551059 - ..
551060 - L E S V D I A L A T I O N
551061 - Interval from - to
551062 - Months Date mm mm
551063 - 8 151204 10 15.....triamcinolone.... ref SDS 0 HU42
551064 - 6 150421 16.5 18.....triamcinolone.... ref SDS D3 HU42
551065 - 6 141107 15 18.....triamcinolone.... ref SDS C4 I167
551066 - 6 140509 16.5 18...................... ref SDS B4 P680
551067 - 7 131115 16.5 18.....triamcinolone.... ref SDS A6 RZ45
551068 - 3 130416 18 18.....triamcinolone.... ref SDS A0 Y850
551069 - 4 130110 15 18.....triamcinolone.... ref SDS 95 Q333
551070 - 6 120925 15 18.....triamcinolone.... ref SDS 87 XB51
551071 - 4 120322 16.5 18...................... ref SDS 84 516N
551072 - 3 111115 16.5 18...................... ref SDS 82 IR57
551073 - 4 110819 15 16.5...triamcinolone.... ref SDS 81 J978
551074 - 3 110429 13 16.5...triamcinolone.... ref SDS 76 U23I
551075 - 3 110218 11 14.....triamcinolone.... ref SDS 72 AA5O
551076 - 4 101210 11 14...................... ref SDS 67 H347
551077 - 5 100827 11 15...................... ref SDS 55 JE6X
551078 - 3 100305 11 15...................... ref SDS 48 WR6L
551079 - 091216 Heller Myotomy Fundoplication... ref SDS 36 KE9U
551081 - ..
551082 - Progress Notes EGD Dilation procedure on 151204 continues...
551083 -
551084 - 2. The patient relates some side effects that he associates
551085 - with the use of omeprazole. We will attempt adjustment of
551086 - his anti-acid medications.
551088 - ..
551089 - 12. RECOMMENDATIONS:
551090 -
551091 - 1. Continue omeprazole 20 mg to be taken 30 minutes prior to
551092 - the evening meal.
551094 - ..
551095 - Ranitidine 300 mg at bedtime.
551097 - ..
551098 - Oral antacid therapy also to be taken at bedtime. Starting
551099 - dose to be 30 mL of Maalox or Mylanta at bedtime.
551100 -
551101 - 1. Await the pathology results.
551103 - ..
551104 - 2. Repeat EGD and dilation in approximately 6 months.
551106 - ..
551107 - EGD dilation interval of 6 months with contraction LESV 10 mm and
551108 - dilation to 15 mm, appears conflicting with patient history.
551109 - ref SDS 0 P45G
551110 -
551111 - [On 160106 2131 letter to Doctor Lee confirms planning for
551112 - EGD dilations on 3 month intervals, and schedule next EGD
551113 - dilation OA 160304 0800. ref SDS G1 T257
551115 - ..
551116 - Progress Notes EGD Dilation procedure on 151204 continues...
551117 -
551118 - 13. DISPOSITION:
551119 -
551120 - 1. The patient was observed in the Recovery Room then
551121 - discharged to home with a companion.
551123 - ..
551124 - 2. I reviewed the endoscopic findings with the patient prior
551125 - to discharge.
551127 - ..
551128 - 14. TIME START: 0909 hours.
551129 - TIME END: 0935 hours.
551131 - ..
551132 - D: 12/04/2015
551133 - T: 12/04/2015
551134 - Job Number: 1518702
551135 - 15. VJJ/CMTS
551136 - $end:
551138 - ..
551139 - The doctor seems to have appended a section of the biopsy report to
551140 - the end of Progress Notes in order to enter a relevant comment.
551141 - ref SDS 0 9P4N
551143 - ..
551144 - Progress Notes EGD Dilation procedure on 151204 continues...
551145 -
551146 - Microscopic exam/diagnosis: (Date Spec taken: Dec 04,
551147 - 2015)
551149 - ..
551150 - A. STOMACH, ANTRUM (BIOPSY):
551151 -
551152 - 1. CHRONIC GASTRITIS
551153 -
551154 - 2. NO EVIDENCE OF HELICOBACTER PYLORI BY WARTHIN STARRY
551155 - STAIN
551157 - ..
551158 - B. STOMACH, BODY (BIOPSY):
551159 -
551160 - - CHRONIC GASTRITIS
551161 -
551162 - - PROTON PUMP INHIBITOR EFFECT
551163 -
551165 - ..
551166 - No significant change from prior pathology.
551167 -
551168 - /es/Randall E. Lee, MD
551169 - Staff Physican, Gastronenterology
551170 - Signed: 12/10/2015 0816
551172 - ..
551173 - This indicates Progress Notes were signed during the morning and
551174 - prior to meeting with the doctor scheduled on 151210 0800, but the
551175 - meeting did not actually occur until OA 0820 or 0830.
551176 -
551177 -
551179 - ..
551180 - Biopsy Reports No Barrett's Esophabus Precursor to Cancer
551181 -
551182 - Follow up ref SDS D3 1B5F, ref SDS C2 1B5F.
551183 -
551184 - 1. VA Pathology Reports
551185 -
551186 - 1. Type of Report: Surgical Pathology
551188 - ..
551189 - 2. Reporting Lab: SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]
551190 - 10535 HOSPITAL WAY MATHER, CA 95655-4200
551192 - ..
551193 - 3. Date Spec taken: Dec 04, 2015 Pathologist: Pathologist:FRANK MELGOZA MD
551194 - Date Spec rec'd: Dec 07, 2015 09:18 Resident: ANANYA DATTA-MITRA md
551195 - Date completed: Dec 08, 2015 Accession #: SP 15 10167
551196 - Submitted by: LEE,RANDALL E Practitioner: RANDALL E LEE MD
551198 - ..
551199 - Specimen: A GASTRIC ANTRUM BIOPSY
551200 - B GASTRIC BODY BIOPSY
551202 - ..
551203 - 4. Brief Clinical History:
551205 - ..
551206 - 5. DIAGNOSTIC
551208 - ..
551209 - 6. Preoperative Diagnosis:
551210 -
551211 - 70 Y/O MAN WITH HISTORY OF CHRONIC GASTRITIS
551213 - ..
551214 - 7. Operative Findings:
551215 - EGD
551217 - ..
551218 - 8. Postoperative Diagnosis:
551219 -
551220 - ATROPHIC-APPEARING ANTRAL MUCOSA. NORMAL GASTRIC BODY
551221 - MUCOSA
551223 - ..
551224 - 9. Gross description:
551225 -
551226 - A. Received in formalin with proper patient identification
551227 - labeled "gastric antrum biopsy" and multiple fragments
551228 - of pale tan tissue measuring 1.0 x 1.0 x 0.3 cm in
551229 - aggregate. Totally submitted in one cassette.
551231 - ..
551232 - B. Received in formalin with proper patient identification
551233 - labeled "gastric body biopsy" and multiple fragments of
551234 - pale tan tissue measuring 0.9 x 0.7 x 0.3 cm in
551235 - aggregate. Totally submitted in one cassette. (ADM
551236 - 12/7/2015 10:43 AM)
551238 - ..
551239 - 10. Microscopic exam/diagnosis: (Date Spec taken: Dec 04,
551240 - 2015)
551242 - ..
551243 - A. STOMACH, ANTRUM (BIOPSY):
551244 -
551245 - 1. CHRONIC GASTRITIS
551246 -
551247 - 2. NO EVIDENCE OF HELICOBACTER PYLORI BY WARTHIN STARRY
551248 - STAIN
551250 - ..
551251 - B. STOMACH, BODY (BIOPSY):
551252 -
551253 - - CHRONIC GASTRITIS
551254 -
551255 - - PROTON PUMP INHIBITOR EFFECT
551257 - ..
551258 - What is PPI effect? Does this relate to PPI damaging endothelium
551259 - reported in findings for study in the record on 150611 0713.
551260 - ref SDS E0 VC5O
551262 - ..
551263 - It is a new finding no presented in prior biopsy reports for past 5
551264 - years.
551266 - ..
551267 - This could mean the stomach shows positive response to treatment with
551268 - Omeprazole PPI???
551270 - ..
551271 - Biopsy Report on 151204 continues...
551272 -
551273 - Performing Laboratory:
551274 - Surgical Pathology Report Performed By:
551275 - SACRAMENTO VAMC [CLIA# 05D0988241]
551276 - 10535 HOSPITAL WAY MATHER, CA 95655-4200
551277 -
551278 -
551279 -
5513 -
SUBJECTS
Default Null Subject Account for Blank Record
5603 -
560401 - ..
560402 - EGD Dilation Pre-Procedure Note
560403 -
560404 -
560405 - LOCAL TITLE: Pre-Procedure Note 60302
560406 - STANDARD TITLE: PROCEDURE NOTE
560407 - DATE OF NOTE: DEC 04, 2015@08:00 ENTRY DATE: DEC 04, 2015@08:41:27
560408 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
560409 - URGENCY: STATUS: COMPLETED
560411 - ..
560412 - DATE AND TIME OF PROCEDURE: Dec 4,2015@08:00
560414 - ..
560415 - CONSENT (select ONE option): I-Med note by procedure prov
560416 -
560418 - ..
560419 - PROCEDURE: egd dilation
560420 - PROVIDER: relee
560421 - INDICATION: esophageal stricture
560422 - ALLERGIES: Reviewed; CPRS up to date
560423 - SITE: egd
560424 - SIDE: N/A
560426 - ..
560427 - CHECKLIST ITEMS:
560428 - 1. Name confirmed
560429 - 2. DOB confirmed
560430 - 3. SSN confirmed
560431 - 4. MD/Pt confirmed procedure
560432 - 5. All equipment good to go
560433 - 6. All staff in agreement
560435 - ..
560436 - CHECKLIST STATUS: Items 1-6 have been confirmed
560438 - ..
560439 - MODERATE SEDATION PRE-PROCEDURE NOTE:
560440 - ASA Level: 2.0
560442 - ..
560443 - MD/DENTIST/NP ASSESSMENT:
560444 - PATIENT HISTORY:
560445 - NEURO:
560446 - Stroke/Encephalopathy: No
560448 - ..
560449 - AIRWAY:
560450 - Prior problems with intubation: No
560451 - Recent stridor/snoring: No
560453 - ..
560454 - RESP:
560455 - Chronic Bronchitis/Emphysema/Asthma: No
560456 - No history of OSA.
560458 - ..
560459 - INFECTIOUS DISEASE:
560460 - AIDS/Hepatitis: No
560462 - ..
560463 - GI/GU:
560464 - Kidney Disease: No
560465 - Liver Disease: No
560467 - ..
560468 - ENDOCRINE:
560469 - Diabetes? No
560471 - ..
560472 - CV:
560473 - HTN: No
560474 - MI/Angina: Yes
560475 - CHF: No
560476 - AICD/Pacemaker: No
560477 - Prosthetic Heart Valve: No
560479 - ..
560480 - OTHER:
560481 - Tobacco: No
560482 - ETOH: No
560483 - Illicit drug use: No
560485 - ..
560486 - PHYSICAL ASSESSMENT:
560487 - Vitals - most recent
560488 - Temp:97.4 F [36.3 C] (12/04/2015 07:57)
560489 - BP: 121/67 (12/04/2015 07:57)
560490 - HR: 60 (12/04/2015 07:57)
560491 - RR: 16 (12/04/2015 07:57)
560492 - WT: 185 lb [84.1 kg] (12/04/2015 07:57)
560493 - HT: 66 in [167.6 cm] (05/09/2014 08:39)
560495 - ..
560496 - PHYSICAL ASSESSMENT:
560497 - Mental Status: Alert, Oriented to: person, place, date,
560498 - situation
560499 - Airway: Can patient open mouth wide? Yes
560500 - Can patient stick out tongue? Yes
560501 - Restricted movement of the neck? No
560502 - Uvula fully visible when mouth open? Yes
560504 - ..
560505 - Comments:
560507 - ..
560508 - Lungs: CTA Bilaterally
560509 - Heart: REGULAR, NO MURMURS
560510 - Exam specific to procedure:
560512 - ..
560513 - Medications:
560514 - Active Outpatient Medications (excluding Supplies):
560515 - ===================================================
560516 -
560517 - 1. OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH ACTIVE
560518 - TWICE A DAY - 15 MINUTES BEFORE A MEAL FOR SEVERE
560519 - ACID REFLUX AND ESOPHAGEAL NARROWING. **NOTE DOSE
560520 - REDUCTION**
560522 - ..
560523 - Active Non-VA Medications Status
560524 - ===================================================
560525 - 1. Non-VA GLUCOSAMINE/CHONDROITIN 1500/1200MG TAB 1 ACTIVE
560526 - CAP/TAB MOUTH EVERY DAY
560527 -
560528 - 2 Total Medications
560530 - ..
560531 - Active medications are listed on 151217 1503. ref SDS F7 6H6K
560533 - ..
560534 - Pre-Procedure Note EGD Dilation on 151204 continues...
560535 -
560536 - Diagnostics: No new diagnostics reguired.
560538 - ..
560539 - Pertinent diagnostic data has been reviewed, significant
560540 - findings
560541 - below:
560543 - ..
560544 - Date and time of last oral intake:
560546 - ..
560547 - Nature (type) and amount of last oral intake:
560548 - see rn note
560550 - ..
560551 - MODERATE SEDATION PLAN:
560552 - Sedation/Anesthesia options, benefits, and risks were discussed
560553 - including: nausea/vomiting, allergic reactions, unexpected
560554 - cardiac or pulmonary problems, and cardiac arrest. Patient
560555 - expressed understanding and wishes to proceed with planned
560556 - sedation/anesthesia.
560558 - ..
560559 - Did a family member or companion accompany the patient and
560560 - participate in the discussion and Interview? No
560561 -
560562 - /es/ Randall E. Lee, MD
560563 - Staff Physician, Gastroenterology
560564 - Signed: 12/04/2015 08:44
560565 -
560566 -
560567 -
5606 -
SUBJECTS
Default Null Subject Account for Blank Record
5703 -
570401 - ..
570402 - Discharge Instructions Blank No Signature No Date
570403 -
570404 - Follow up ref SDS A6 U76O.
570405 -
570406 - LOCAL TITLE: GI Discharge Instructions
570407 - STANDARD TITLE: GASTROENTEROLOGY NURSING NOTE
570408 - DATE OF NOTE: DEC 04, 2015@09:59 ENTRY DATE: DEC 04, 2015@09:59:46
570409 - AUTHOR: OPADA,A CHRISTIE EXP COSIGNER:
570410 - URGENCY: STATUS: COMPLETED
570412 - ..
570413 - VANCHCS GI Clinic Discharge Instructions::
570415 - ..
570416 - -Do not drive a motor vehicle, operate machinery, or make
570417 - important decisions for at least 24 hours after your procedure.
570418 - The medication given during your procedure may make you dizzy
570419 - and sleepy and will affect how you act and think.
570421 - ..
570422 - -You may resume a normal diet after you leave today unless
570423 - instructed otherwise. However, for the first meal please eat
570424 - light food, nothing greasy or spicy.
570426 - ..
570427 - -During your procedure the doctor added air into your GI tract
570428 - so you may experience some abdominal bloating and cramping.
570429 - The sooner you can pass the air the better you will feel. The
570430 - discomfort or bloating will subside in a few hours but may last
570431 - all day.
570433 - ..
570434 - -If you have any of the following symptoms, please call the
570435 - clinic at (916) 366-5339 for advice.
570436 -
570437 - A. Passing or vomiting large amounts of blood.
570438 - B. Passing black or tarry stools.
570439 - C. Fever over 100° with or without chills.
570440 - D. Severe tenderness or redness at IV needle puncture site.
570441 - E. Severe abdominal or chest pain.
570442 - F. Shortness of breath or tightness in the chest.
570443 - G. Loss of consciousness or frequent bouts of dizziness.
570444 -
570446 - ..
570447 - -MEDICATIONS: You may resume your medications after the
570448 - procedure unless instructed otherwise by your physician.
570449 - Resume ALL MEDICATIONS on Dec 4,2015
570451 - ..
570452 - Dilation:
570453 -
570454 - -Start with liquids, and then resume diet as tolerated.
570455 - --Some pain or discomfort is expected if severe call GI Clinic or go to
570456 - ER.
570457 - EGD, EUS, or Enteroscopy:
570458 -
570459 - -a mild sore throat can be helped by cough drops, or a salt-water gargle.
570460 - -Wait a half-hour after the exam before drinking liquids, as oral
570461 - anesthetic may have been used to numb the throat.
570462 - -Call or return to ER if difficulty swallowing or breathing, neck
570463 - swelling, excessive pain, nausea or vomiting, abdominal distension, fever.
570465 - ..
570466 - GI Clinic phone number (916) 366-5339 (8:00am-4:30pm)
570467 - After 4:30pm, weekends and holidays, please call (800) 382-8387
570469 - ..
570470 - Follow Up:
570471 - Primary Provider
570473 - ..
570474 - HANDOUTS GIVEN ON GERD, REFLUX PRECAUTIONS.
570476 - ..
570477 - POST-OP INSTRUCTION given to patient and responsible adult.
570478 - Verbalized understanding.
570480 - ..
570481 - If you would like a copy of your procedure report, please
570482 - contact Release of Information (ROI) at (916) 843 7005.
570483 -
570484 - /es/ A. Christie Opada, RN, BSN
570485 - Staff Nurse, GI Clinic
570486 - Signed: 12/04/2015 11:36
570487 -
570488 -
570489 -
570490 -
570491 -
570492 -
570493 -
570494 -
570495 -
570496 -
570497 -
570498 -
570499 -
570500 -
570501 -