CONTACTS
SUBJECTS
VA Achalasia Schedule Next EGD Dilation 4 Months Recover Worst Ever
2903 -
2903 - ..
2904 - Summary/Objective
2905 -
290501 - Follow up ref SDS 22 0000, ref SDS 21 0000.
290502 -
290503 - Doctor Lee confirmed prescription for Mylanta 30 ml per day, and
290504 - ordered 3 month supply. ref SDS 0 WZ7I Reduced prescription for
290505 - Omperazole from 1 20 mg pill every day, to 1 pill every other day, in
290506 - order to reduce liver damage that causes frequent urination that
290507 - causes dehydration. This will hopefully enable feet injuries to
290508 - recover, so that hiking can continue extended endurance exercise
290509 - required to recover from atherosclerosis. ref SDS 0 J56O Doctor Lee
290510 - changed prescription for Ranitidine H2 Blocker and switched to
290511 - Famotidine which is smaller and so easier to swallow than Ranitidine.
290512 - ref SDS 0 RH6N The doctor ordered next EGD dilation in 4 months
290513 - because prior achalasia condition caused LESV to contract to 10 mm,
290514 - worst condition in patient history, and so was able to dilate to only
290515 - 15 mm. ref SDS 0 UR5K
290516 -
290517 -
290518 -
290519 -
290520 -
290522 - ..
2906 -
2907 -
2908 - Progress
2909 -
290901 - Meeting today, was scheduled on 150925 0336. ref SDS 19 QR5O
290902 -
290903 - Agenda was submitted to the doctor in a letter sent on 151208 1943.
290904 - ref SDS 22 4M6G
290905 -
290906 - 1. Progress Notes EGD dilation on 151204, obtain the file.
290907 -
290908 - Review adverse findings
290910 - ..
290911 - 2. Mylanta - verify dose 15 or 30 ml
290913 - ..
290914 - Doctor Lee confirmed that he prescribed 30 ml per day to compliment
290915 - Ranitidine, when he placed orders for both medications last week on
290916 - 151204 0800. ref SDS 21 689J
290918 - ..
290919 - During the meeting, Doctor Lee ordered a 3 month prescription for
290920 - Mylanta. We had to do a manual calculation to convert "2 Teaspoons"
290921 - shown on the medication bottle, into "10 ml" in order to calculate the
290922 - number of bottles to order that contain 360 ml. Actually, the direct
290923 - calculation is taking 30 ml per day prescribed by Doctor Lee,
290924 - indicates a bottle will last only 12 days. He ordered 10 bottles,
290925 - which should last 120 days, which is about 4 months, until the next
290926 - EGD dilation that should occur OA 160304.
290927 -
290928 - [On 151217 1503 received refill for Famotidine, but not
290929 - refill for Mylanta - both ordered the same day on 151210.
290930 - ref SDS 23 6H6K
290932 - ..
290933 - [On 151221 0747 notified Doctor Lee there is about 3 days
290934 - supply of Mylanta; VA Pharmacy schedules prescription
290935 - refill for Mylanta ordered on 151210, will not be filled
290936 - until 151225, indicating delivery to customer OA 151228;
290937 - request intervention to expedite delivery. ref SDS 24 IF83
290939 - ..
290940 - [On 151225 1222 received Mylanta 360 ml 8 bottles, ordered
290941 - by Doctor Lee on 151210. ref SDS 25 5N3O
290943 - ..
290944 - The remaining medication received from original order placed
290945 - by Doctor Lee last week on 151204 0800, ref SDS 21 689J, can be used
290946 - until the new prescription is received.
290947 -
290949 - ..
290950 - 3. Omeprazole eliminate or reduce if possible and replace or
290951 - supplement with Mylanta and Famotidine or Ranitidine are H2
290952 - blockers that restrain production of acid, explained below...
290954 - ..
290955 - Avoid painful reflux
290957 - ..
290958 - Avoid ulceration LESV caused by reflux
290960 - ..
290961 - Doctor Lee drew a diagram to illustrate different biological
290962 - processes between Omeprazole Proton Pump Inhibitor, and H2 Blocker
290963 - Famotidine...
290964 -
290965 -
290966 - \ S t o m a c h /
290967 -
290968 - \ / Omeprazole
290969 - \ /
290970 - \ / Proton Pump Inhibitor
290971 - \ /
290972 - - - - - - Contains and suppresses all acid from
290973 - / \ Acid Pump, and so is generally
290974 - / Acid \ more effective than H2 Blocker medications
290975 - / Pump H+ \
290976 - / \
290977 - H2 / +---+ +---+ \
290978 - Receptor / | | | | \
290979 - ++-------------------+
290980 -
290982 - ..
290983 - Acid pump at bottom of stomach excretes different types of acid
290984 - through "receptors. One is an H2 Receptor.
290986 - ..
290987 - Famotidine and Ranitidine are H2 blockers that restrain production of
290988 - acid from only the H2 receptor.
290990 - ..
290991 - Famotidine H2 blocker was ordered by Doctor Stewart during a meeting
290992 - at the VA Medical Center in San Francisco, on 150623, to try
290993 - supplementing Omeprazole. ref SDS 18 TX6M This was received a week
290994 - later, but has been taken only 2 or 3 time. Most of the prescription
290995 - is still on hand.
290997 - ..
290998 - Ranitidine H2 Blocker was ordered by Doctor Lee to replace Famotidine.
290999 - The order was placed last week during a meeting with Doctor lee at the
291000 - VA Medical Center in Sacramento on 151204. ref SDS 21 689J Later that
291001 - day on 151204, Kathy went back to the VA and received the prescription
291002 - for Ranitidine. ref SDS 21 UC6N
291004 - ..
291005 - Today, considered whether to continue with Famotidine or Ranitidine?
291007 - ..
291008 - Since Ranitidine pills are much bigger than Famotidine they are harder
291009 - to swallow. Since the problem to solve with this line of care for
291010 - achalasia is difficulty swallowing, decided to continue with smaller
291011 - Famotidine that are easier to swallow.
291013 - ..
291014 - During the meeting, Doctor Lee ordered a 3 month prescription for
291015 - Famotidine. The remaining pills received from original order placed
291016 - by Doctor Stewart, can be used until the new prescription is
291017 - received next week.
291018 -
291019 - [On 151217 1503 received prescription for Famotidine from
291020 - Pharmacy at VA Medical Center in Sacramento. ref SDS 23 5N3O
291021 -
291023 - ..
291024 - 4. Liver damage evaluate based on symptoms frequent and increased
291025 - volume urination, greater than consumption
291027 - ..
291028 - Bilirubin elevated for several years
291030 - ..
291031 - 5. Endothelium lining blood vessels damaged taking Omeprazole PPI
291032 - past 5 years, based on study, reported on 150611 0713.
291033 - ref SDS 17 VC5O
291035 - ..
291036 - CCTA performed on 151019, does not report damage to
291037 - endothelium; can the CT scan be examined for this issue, or
291038 - does another CT test need to be performed with specialized
291039 - contrast?
291041 - ..
291042 - 6. Progress Notes and photographs on CD.
291044 - ..
291045 - Doctor Lee advised he cannot provide Progress Notes with photographs
291046 - for meeting on 151204 0800. ref SDS 21 5H5J
291048 - ..
291049 - Will have to order records of treatment from ROI.
291051 - ..
291052 - 7. Next EGD dilation procedure
291054 - ..
291055 - Doctor Lee wants this scheduled in 4 months, rather than 6 month
291056 - intervals used the past 3 years. This will enable patient to recover
291057 - from worst ever contraction of LESV from 18 mm down to 10 mm reported
291058 - on 151204 0800. ref SDS 21 PA9G
291060 - ..
291061 - After the meeting with Doctor Lee, met with Jessica in the admin
291062 - office for EGD Clinic.
291064 - ..
291065 - Jessica said to call her next month on 160104, to order EGD Dilation
291066 - on 160304, because the VA computer will not accept scheduling for
291067 - Doctor Lee 4 months ahead.
291068 -
291069 -
291070 -
291071 -
2911 -
SUBJECTS
Default Null Subject Account for Blank Record
3003 -
300401 - ..
300402 - Progress Notes EGD Dilation Today
300403 -
300404 - Follow up ref SDS 21 CY7I, ref SDS 16 CY7I.
300405 -
300406 - On 151224 received following medical records on CD and stored in...
300407 -
300408 - F:\05\00003\SM\CC\AGMJ\20151210-080000\WELCH.pdf
300410 - ..
300411 - This file includes numerous reports flowing from EGD Dilation
300412 - procedure on 151204, and follow up meeting a week later on 151210;
300413 - there is no particular order for the records in this file...
300414 -
300415 - 1. LOCAL TITLE: Gastroenterology Attending F/U Note 60127
300416 - STANDARD TITLE: GASTROENTEROLOGY ATTENDING NOTE
300417 - DATE OF NOTE: DEC 10, 2015@08:00 ENTRY DATE: DEC 10, 2015@14:40:41
300418 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
300419 - URGENCY: STATUS: COMPLETED
300420 -
300421 - *** Gastroenterology Attending F/U Note 60127 Has ADDENDA ***
300422 -
300423 - fu 1522117 dictated
300424 -
300425 - /es/ Randall E. Lee, MD
300426 - Staff Physician, Gastroenterology
300427 - Signed: 12/10/2015 14:41
300429 - ..
300430 - 2. HISTORY OF PRESENT ILLNESS:
300432 - ..
300435 - ..
300436 - 3. 70-year-old man seen and examined on 12/10/2015 at 8:00 a.m.
300437 - for review of his recent EGD findings and adjustment of his
300438 - medication. His identity is confirmed times 2.
300440 - ..
300441 - 4. He has a history of achalasia and in late 2009 underwent a
300442 - laparoscopic myotomy and fundoplication at the San Francisco
300443 - VA. He developed acid reflux complicated by recurrent distal
300444 - esophageal stricture with ulceration and erosion. This
300445 - initially was treated with high dose proton pump inhibitor
300446 - therapy, but due to interval development of associated foot
300447 - discomfort and frequent urination he has begun adjusting his
300448 - omeprazole and requesting reduction in dose. His EGD of
300449 - 12/04/2015 was significant for recurrence of a distal
300450 - esophageal stricture that impeded passage of the 9.8 mm
300451 - diameter gastroscope. This underwent TTS balloon dilation to
300452 - 15 mm. There was some associated shallow ulcer/erosion
300453 - immediately proximal to the esophageal stricture.
300455 - ..
300456 - 5. Currently, the patient reports having an improvement in his
300457 - dysphagia. I had prescribed for him ranitidine 300 mg at
300458 - bedtime, but he reports having difficulty with this medication
300459 - because of the size of the pill.
300461 - ..
300462 - 6. We had a very lengthy discussion wherein we reviewed the
300463 - pharmacology of H2 receptor blockers, as well as proton pump
300464 - inhibitors, and we reviewed the endoscopic findings and images.
300465 - He reports having some breakthrough symptoms at night for which
300466 - he used sodium bicarbonate with rapid, but short lived relief.
300467 - He also reports that in the past he has tried completely
300468 - stopping omeprazole, but noted a marked increase in severity of
300469 - his upper gastrointestinal symptoms.
300471 - ..
300472 - 7. PHYSICAL EXAMINATION:
300473 -
300474 - GENERAL: Awake, alert, and oriented.
300476 - ..
300477 - 8. IMPRESSION:
300478 -
300479 - Recurrent peptic stricture at the distal esophagus with
300480 - associated erosions/ulcerations. There has been no evidence of
300481 - malignancy. Based on these recurrent findings, I believe it is
300482 - likely the patient will require continuous acid suppression.
300483 - He is reporting side effects he believes are associated with
300484 - omeprazole. He also has concerns about the long term effects
300485 - this might have on his liver. After much discussion, we agreed
300486 - with the following regimen.
300488 - ..
300489 - 9. RECOMMENDATIONS:
300490 -
300491 - 1. Omeprazole to be reduced to 20 mg every other day.
300493 - ..
300494 - 2. Switch ranitidine to famotidine at a dose of 20 mg at
300495 - bedtime.
300497 - ..
300498 - 3. Liquid antacid 30 mL also at bedtime.
300500 - ..
300501 - 4. Reevaluate symptoms and repeat EGD in approximately 4-6
300502 - months.
300504 - ..
300505 - This seems conflicting with understandings during the meeting - Doctor
300506 - Lee seemed to say the next meeting would be in 4 months. ref SDS 0
300507 - UR5K
300509 - ..
300510 - Patient history indicates when LESV contracts below 16 mm, and when
300511 - esophagus was swelled and distorted, reported by CT test on 151019
300512 - 0930, ref SDS 20 YY4H, EGD dilations were performed on 3 - 4 month
300513 - intervals.
300514 -
300515 - L E S V
300516 - Months Dilate from - to
300517 - Interval Date mm mm
300518 - 6 150421 16.5 18.....triamcinolone.... ref SDS 16 HU42
300519 - 6 141107 15 18.....triamcinolone.... ref SDS 15 I167
300520 - 6 140509 16.5 18...................... ref SDS 14 P680
300521 - 7 131115 16.5 18.....triamcinolone.... ref SDS 13 RZ45
300522 - 3 130416 18 18.....triamcinolone.... ref SDS 12 Y850
300523 - 4 130110 15 18.....triamcinolone.... ref SDS 11 Q333
300524 - 6 120925 15 18.....triamcinolone.... ref SDS 10 XB51
300525 - 4 120322 16.5 18...................... ref SDS 9 516N
300526 - 3 111115 16.5 18...................... ref SDS 8 IR57
300527 - 4 110819 15 16.5...triamcinolone.... ref SDS 7 J978
300528 - 3 110429 13 16.5...triamcinolone.... ref SDS 6 U23I
300529 - 3 110218 11 14.....triamcinolone.... ref SDS 5 AA5O
300530 - 4 101210 11 14...................... ref SDS 4 H347
300531 - 5 100827 11 15...................... ref SDS 3 JE6X
300532 - 3 100305 11 15...................... ref SDS 2 WR6L
300533 - 091216 Heller Myotomy Fundoplication ref SDS 1 KE9U
300534 -
300536 - ..
300537 - 5. The patient may increase his famotidine from 20 mg to 40 mg
300538 - should he feel the need for increased acid suppression.
300540 - ..
300541 - Will try this instead of relying on Baking Soda.
300543 - ..
300544 - D: 12/10/2015
300545 - T: 12/11/2015
300546 - Job number: 1522117
300547 - MKG/CMTS
300548 - $end:
300549 -
300550 - /es/ Randall E. Lee, MD
300551 - Staff Physician, Gastroenterology
300552 - Signed: 12/16/2015 16:32
300553 -
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3006 -