CONTACTS
SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10
2503 -
2503 - ..
2504 - Summary/Objective
2505 -
250501 - Follow up ref SDS G6 0000. ref SDS F3 0000.
250502 -
250503 - Diffuculty swallowing this cycle began about 2 months after prior EGD
250504 - dilation on 160315. ref SDS 0 P55L Reported ending baking soda to
250505 - relieve reflux that prevents ulceration LESV. ref SDS 0 G53K EGD
250506 - dilation procedure went smoothly, with no reports of difficulties.
250507 - ref SDS 0 7V6I Post procedure Doctor Lee reported LESV contracted to
250508 - 9.5 mm, the smallest in patient history, indicating 2 month delay to 8
250509 - months performing procedure in December causing continual injury.
250510 - ref SDS 0 5H5J Ulceration that cleared up taking Baking Soda during
250511 - prior cycle, got worse this past cycle after stopping Baking Soda.
250512 - ref SDS 0 RZ3G Trying Famotidine increase to 40 mg twice per day.
250513 - ref SDS 0 Q05K Next meeting in 3 months. ref SDS 0 4U5F
250514 -
250515 -
250516 -
250517 -
250518 -
250520 - ..
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 F3 GD4H
251358 - Preparation for the procedure was professional; no difficulties
251359 - setting IV for conscious sedation today. ref SDS F3 544G The doctor
251360 - reported not receiving letter with agenda for the meeting today,
251361 - submitted on 151201. ref SDS F3 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 F3 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 F3 G53K Performing EGD dilation procedure went
251369 - smoothly, with no difficulties. ref SDS F3 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 F3 5H5J
251374 - ..
251375 - On 151210 meeting Doctor Lee after EGD on 151204, changed prescription
251376 - of Omeprazole (PPI) to 20 mg every other day to eliminate or reduce
251377 - dehydration from frequent urination, and in order for feet to recover
251378 - from peeling, cracking, bleeding so that hiking can be performed at
251379 - level of 300 miles per month required to raise HDL > 60, required to
251380 - regress athersclerosis. ref SDS F6 J56O Doctor prescribed adding
251381 - Famotidine an H2 blocker taken once a day to compliment Omeprazole.
251382 - ref SDS F6 YL3M
251384 - ..
251385 - On 160325 0900 Diffuculty swallowing this cycle began about 1 month
251386 - after prior EGD dilation on 151204. ref SDS G6 P55L Reported using
251387 - baking soda to relieve reflux that prevents ulceration LESV; this
251388 - reduced Omeprazole in order to avoid dehydration. ref SDS G6 Z84H
251389 - Progress Notes report there is no longer any erosive esophagitis and
251390 - there is no evidence of mass effect, which implies better acid
251391 - suppression compared to previous examination December 2015.
251392 - ref SDS G6 PXXY EGD dilation procedure went smoothly, with no reports
251393 - of difficulties. ref SDS G6 7V6I Post procedure Doctor Lee reported
251394 - LESV contracted to 9.5 mm, the smallest in patient history, indicating
251395 - 2 month delay to 8 months performing procedure in December causing
251396 - continual injury. ref SDS G6 5H5J
251397 -
251398 -
251399 -
251400 -
251401 -
251403 - ..
2515 -
2516 -
2517 - Progress
251801 - ..
251802 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration
251803 - GI Department VA Sacramento Medical Center Administration EGD Dilation
251804 -
251805 - Follow up ref SDS G6 NU8L, ref SDS F3 NU8L.
251806 -
251807 - Meeting today implements planning for next EGD dilation in 3 months,
251808 - reported in meeting with Doctor Lee on 160315 0900. ref SDS G6 4U5F
251809 - The doctor's Progress Notes say 3 months. ref SDS G6 NV4K Patient
251810 - history indicates LESV contraction to 9.5 mm requires 3 month
251811 - treatment cycles. ref SDS G6 LD8O
251813 - ..
251814 - No agenda was submitted for meeting today.
251816 - ..
251817 - Applied pre-proc requirements for NPO after midnight, from letter on
251818 - 101015 1547. ref SDS 59 4J9L Last food was at......
251820 - ..
251821 - Stayed in Concord last night. This morning, Kathy drove us to VA
251822 - Medical Center at Mather AFB in Sacrmento.
251824 - ..
251825 - Checked into GI Department at the customer counter..
251826 -
251827 - 800-382-8387
251828 -
251829 - 916 843 7000
251831 - ..
251832 - Kathy cell phone for designated driver...
251836 - ..
251837 - Kathy signed the discharge form affirming she will be designated
251838 - driver, and responsible to facilitate no driving for 24 hours.
251840 - ..
251841 - Nurse at customer counter asked questions on patient history to verify
251842 - ready for procedure, e.g., no allergies, and NPO after midnight to
251843 - avoid conflicts with anesthesia; no health problems, e.g., no
251844 - diabetes, alcohol, cigarettes.
251846 - ..
251847 - Waited in lobby for 10 minutes. Then Jessica called to prepare for
251848 - procedure.
251849 -
251851 - ..
2519 -
2520 -
2521 - 0817
2522 -
252201 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV
252202 -
252203 - Follow up ref SDS G6 EP75, ref SDS F3 EP75.
252204 -
252205 - Ed took vitals today, prior to procedure in a small office just off
252206 - the lobby, and not in the treatment center, reported on 120925 0900.
252207 - ref SDS 87 PT5P
252209 - ..
252210 - Vital included...
252211 -
252212 - Weight.................. 186 (fully dressed, shoes, cell phone)
252213 - BP...................... 144 72
252214 - HR (pulse).............. 54
252215 - Temp.................... 97
252217 - ..
252218 - Returned to patient waiting area.
252220 - ..
252221 - In about 5 minutes, Grace called patient into OR preparation room, and
252222 - assisted with dressing down and laying on a gurney.
252224 - ..
252225 - Grace configured on gurney and connected equipment to monitor vitals
252226 - during the procedure.
252228 - ..
252229 - Jo set catheter IV for sedation. Required only 1 stick, so better
252230 - day than last time on 141107 0800. ref SDS C4 544G
252232 - ..
252233 - Case study on sticks required to set catheter is reported on 110429
252234 - 1230. ref SDS 76 UO3G
252236 - ..
252237 - Grace went through patient identification and medical profile filling
252238 - out forms on the computer.
252240 - ..
252241 - She asked about pain? Reported level 0.
252243 - ..
252244 - Waited about 40 minutes.
252245 -
252246 -
252247 -
252249 - ..
2523 -
2524 -
2525 - 0900
2526 -
252601 - Consent Signed EGD Dilation and Meeting Review Pending Issues
252602 - Consultation Pending Issues and Sign Consent for EGD Dilation
252603 -
252604 - Follow up ref SDS G6 RG9K, ref SDS F3 RG9K.
252605 -
252606 - Meeting Doctor Lee to sign form consenting to undergo EGD dilation
252607 - procedure today.
252609 - ..
252610 - Noted that signature is entered on completely black screen, required
252611 - without reading online documents.
252613 - ..
252614 - Asked about sleeping an extra hour today. Doctor Lee asked the lead
252615 - nurse, if the patient sleeping an extra hour would be okay.
252617 - ..
252618 - She said they are not very busy today, so the nurses will allow the
252619 - patient to sleep until he awakens naturally, or at least an hour
252620 - longer.
252622 - ..
252623 - Thanked everyone for patient support.
252624 -
252625 -
252626 -
252628 - ..
252629 - Swallowing Vomitting Difficulties Resolved with Triamcinolone Injections
252630 - Triamcinolone Injection Prevent LESV Contraction Avoid Swallowing Vomitting Problems
252631 -
252632 - Follow up ref SDS G6 VV6N, ref SDS F3 VV6N.
252633 -
252634 - Doctor Lee plans to use Triamcinolone steroid injection during the
252635 - procedure today, based on favorable results, and planning during the
252636 - meeting on 150319 0800, ref SDS D0 6P9M, and as applied for subsequent
252637 - EGD dilation shown on 160315 0900. ref SDS G6 LD8O We were both
252638 - disappointed LESV contracted back to 9.5 for the prior procedure on
252639 - 160315, indicating some threshold may have occurred as a result of 2
252640 - month delay performing procedure on 151204 0800. ref SDS F3 5Q4I
252642 - ..
252643 - Doctor Lee asked about swallowing problems?
252645 - ..
252646 - There were isolated episodes of severe vomiting for example on 160516,
252647 - shown in case study on 140101 0600. ref SDS A9 H37O Then swallowing
252648 - was okay until 160605. ref SDS A9 PN6J Since then, it has gotten
252649 - progressively worse, so today is a time for another attempt to expand
252650 - LESV above 15 mm, toward baseline of 18 mm.
252652 - ..
252653 - Estimated LESV will engage today at < 13mm, based on recent swallowing
252654 - problems (e.eg., see beginnon on 160101, in case study on 140101 0600.
252655 - ref SDS A9 UA6K).
252656 -
252657 - [...below on 160617 0800 at 1120 after the procedure Doctor
252658 - Lee reported LESV contracted this cycle to 9.5 mm from 15,
252659 - and so he could only dilate today back to 15 mm.
252660 - ref SDS 0 5H5J
252662 - ..
252663 - Advised that stopped taking Baking Soda to aid swallowing, and reduce
252664 - reliance on Omeprazole for controlling reflux in order to prevent
252665 - ulceration LESV, as recommended by Doctor Lee during the meeting on
252666 - 160315. ref SDS G6 TH7F
252668 - ..
252669 - Research on taking Baking Soda to prevent acid reflux is reported on
252670 - 151204 0800. ref SDS F3 H76M
252672 - ..
252673 - Signed consent for the procedure, which is not visible - there is
252674 - merely a black screen to sign.
252675 -
252676 -
252677 -
252678 -
252680 - ..
2527 -
2528 -
2529 - 0926
2530 -
253001 - OR EGD Dilation with Application Lidocaine
253002 - EGD Dilation Procedure in OR Application Lidocaine
253003 -
253004 - Follow up ref SDS G6 7V6I, ref SDS F3 7V6I.
253005 -
253006 - Jo wheeled the gurney into the OR for the procedure. Met Jocey.
253008 - ..
253009 - Everything went smoothly, as always.
253011 - ..
253012 - Jocey applied conscious sedation using the catheter set by Jo in
253013 - Preparation, per above. ref SDS F3 544G
253014 -
253015 - [...below on 160517 0800 Progress Notes report intravenous
253016 - medication applied for conscious sedation. ref SDS 0 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 G6 5H5J, ref SDS F3 5H5J.
2531 -
2532 -
2533 - 1130
253401 - ..
253402 - An hour or so after the procedure, met with Doctor Lee in the recovery
253403 - room.
253405 - ..
253406 - Doctor Lee advised that EGD examination today, found LESV contracted
253407 - back to 9.5 mm again. Very disappointing there was no improvement
253408 - since the prior procedure 3 months earlier on 160315 0900, ref SDS G6
253409 - 7Q6L, indicating continuing difficulties resulting from 2 month delay
253410 - extending prior 6 month procedures to 8 months on 151204 0800.
253411 - ref SDS F3 6P6G
253413 - ..
253414 - This aligns with Discharge documents which say Dilation 10 - 15, where
253415 - 10 is rounded off from 9.5.
253416 -
253417 - [...below on 160617 0800 Progress Notes seem to say LESV
253418 - contracted to 12mm; seems to be an entry error based on
253419 - post procedure reporting, Discharge document, and
253420 - correlations with patient history. ref SDS 0 HU42
253422 - ..
253423 - Doctor Lee advised that triamcinolone steriod was injected again
253424 - today, in order to restore and maintain swallowing for the next 3
253425 - months, as it has the past 2 years, since 120925...
253427 - ..
253428 - Case study from Progress Notes below, ref SDS 0 LD8O, replicated here
253429 - for convenint reference...
253430 -
253431 - LESV DILATE Triamcin Diphenhy Fenta Bena Midaz Lido
253432 - Months from - to olone Versed dramine nyl dryl olam caine
253433 - Interval Date mm mm mL mg mg mg mg mg mL
253434 - *1 3 160617 9.5 15......5.0.....6..............250.....50...............5...... ref SDS 0 HU42
253435 - *2 4 160315 9.5 15......3.0............25......250.............5........5...... ref SDS G6 HU42
253436 - 8 151204 10 15......5.0............25......200.............5........5...... ref SDS F3 HU42
253437 - 6 150421 16.5 18......3.0............50......250.............4........5...... ref SDS D3 HU42
253438 - 6 141107 15 18......4.0............50......150.............5........5...... ref SDS C4 E54M
253439 - 6 140509 16.5 18.....................50......200.............5........5...... ref SDS B4 P680
253440 - 7 131115 16.5 18......2.0............50......200.............4........5...... ref SDS A6 RZ45
253441 - 3 130416 18 18......2.0.....5..............250.....50...............5...... ref SDS A0 Y850
253442 - 4 130110 15 18......3.0............50......100.............4........5...... ref SDS 95 Q333
253443 - *3 6 120925 15 18......4.0............50......200.............5........5...... ref SDS 87 XB51
253444 - 4 120322 16.5 18.....................50......150.............4........5...... ref SDS 84 516N
253445 - 3 111115 16.5 18.....................50......200.............4........5...... ref SDS 82 IR57
253446 - 4 110819 15 16.5....2.5............50......200.............5........5...... ref SDS 81 J978
253447 - 3 110429 13 16.5....3.5.....5..............200.....50...............5...... ref SDS 76 U23I
253448 - 3 110218 11 14......2.0............50......150.............4........5...... ref SDS 72 AA5O
253449 - 4 101210 11 14......................................................5...... ref SDS 67 H347
253450 - 5 100827 11 15..............5..............250.....50...............5...... ref SDS 55 JE6X
253451 - 3 100305 11 15..............5..............250.....50...............5...... ref SDS 48 WR6L
253452 - 091216 Heller Myotomy Fundoplication....................................... ref SDS 36 KE9U
253454 - ..
253455 - Background on triamcinolone injection is further reviewed in the
253456 - record for the meeting at the VA on 140509 0900. ref SDS B4 R26H
253457 -
253459 - ..
253460 - Ulceration LESV Increased
253461 -
253462 - Follow up ref SDS G6 RZ3G, ref SDS F3 RZ3G.
253463 -
253464 - Doctor Lee reported increased ulceration LESV from prior examination
253465 - on 160315 0900. ref SDS G6 RZ3G
253466 -
253467 - [...below on 160617 0800 Progress Notes say
253468 - Hemi-circumferential distal esophageal ulceration at the
253469 - level of the stricture; this was not present at last
253470 - endoscopy and implied suboptimal acid- suppression in the
253471 - context of QOD PPI (twice daily H2B). ref SDS 0 MA4L
253473 - ..
253474 - This aligns with eliminating Baking Soda, reducing Omeprazole taking
253475 - 20 mg every other day, to prevent debilitating side effects, discussed
253476 - with Doctor Lee on 160315 0900, ref SDS G6 RZ3G; and, further
253477 - increasing Famotidine to 20 mg twice per day, prescribed during prior
253478 - meeting with Doctor Lee on 160315 0900. ref SDS G6 ZQ4H
253480 - ..
253481 - Doctor Lee prescribed increasing Famotidine to 40 mg twice per day
253482 - for resolving increased esophagitis.
253483 -
253484 - [...below on 160617 0800 Progress Notes recommend
253485 - increasing PPI. SDS 0 LF5I
253487 - ..
253488 - Doctor Lee cautioned again against taking Baking Soda to relieve
253489 - reflux, discussed previously on 151204. ref SDS F3 EY9K
253490 -
253491 -
253493 - ..
253494 - Next Meeting 3 Months to Recover Severe Symptoms
253495 -
253496 - Follow up ref SDS G6 4U5F, ref SDS F3 4U5F.
253497 -
253498 - The doctor advised that he prescribed next EGD Dilation in 3 months on
253499 - 160909, in order to prevent severe contraction of LESV to 9.5 mm, that
253500 - occurred over the past 3 months causing severe vomiting, and leading
253501 - to dilation to only 15 mm, rather than standard of care dilating to 18
253502 - mm, per above. ref SDS 0 6P6G
253503 -
253504 - [On 160816 0800 next EGD dilation was performed 3 weeks in
253505 - advance of schedule on 160909, ordered by Doctor Lee today.
253506 - ref SDS H1 NU8L
253507 -
253508 -
253509 -
253510 -
253511 -
253512 -
253513 -
253514 -
253515 -
253516 -
2536 -
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 G6 CY7I, ref SDS F3 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 - Downloaded Progess Notes for procedure on 160617, and stored in...
550421 -
550422 - F:\05\00003\SM\CC\AGMJ\20160617-080000\mhv_WELCH_20160808_0700.txt
550424 - ..
550425 - This file includes numerous reports flowing from EGD Dilation
550426 - procedure on 160617; there is no particular order for the records in
550427 - this file.
550428 -
550430 - ..
550431 - Progress Notes EGD Dilation Today
550432 -
550433 - Follow up ref SDS G6 9N5G, ref SDS F3 9N5G.
550434 -
550435 - 1. Date/Time: 17 Jun 2016 @ 1007
550436 - Note Title: EGD 60111
550437 - Location: No CA Healthcare Sys-Martinez
550438 - Signed By: CHAO,ANDREW
550439 - Co-signed By: CHAO,ANDREW
550440 - Date/Time Signed: 17 Jun 2016 @ 1027
550442 - ..
550443 - LOCAL TITLE: EGD 60111
550444 - STANDARD TITLE: GASTROENTEROLOGY PROCEDURE NOTE
550445 - DATE OF NOTE: JUN 17, 2016@10:07 ENTRY DATE: JUN 17, 2016@10:07:48
550446 - AUTHOR: CHAO,ANDREW EXP COSIGNER: LEE,RANDALL E
550447 - URGENCY: STATUS: COMPLETED
550449 - ..
550450 - ESOPHAGOGASTRODUODENOSCOPY REPORT JUN 17, 2016
550451 -
550455 - ..
550456 - INDICATIONS: The patient is an 71-year-old MALE (BMI 29.2)
550457 - with achalasia in 2009 and subsequent laparoscopic myotomy and
550458 - fundoplication at the San Francisco VA. He then developed acid
550459 - reflux complicated by recurrent distal esophageal stricture
550460 - with EGD and dilation last in 3/2016. He underwent dilation
550461 - from 10-15 mm and received triamcinolone acetate injected into
550462 - the area.
550464 - ..
550465 - Achalasia diagnosed in July 2005.
550467 - ..
550468 - No reason to believe acid reflux developed after Heller Myotomy
550469 - surgery on 091216. It was diagnosed on 100305, because that is the
550470 - first EGD dilation procedure, reported on 100305 1000. ref SDS 48 NF9K
550472 - ..
550473 - EGD Progress Notes on 160617 continue...
550474 -
550475 - He has been continued on QOD omeprazole 20mg and twice daily
550476 - famotidine with symptom-free interval of 2 mo before recurrent
550477 - dysphagia in the last months to solids.
550479 - ..
550480 - PPI Omeprazole is taken 20 mg every other day, shown in case study on
550481 - 140101 0600. ref SDS A9 UU4L
550483 - ..
550484 - EGD Progress Notes on 160617 continue...
550485 -
550486 - PHYSICAL EXAMINATION: The patient is in no acute distress.
550487 - CHEST: Clear. CARDIOVASCULAR: Regular rate. ABDOMINAL:
550488 - Nondistended, normal bowel sounds, soft, nontender.
550489 - EXTREMITIES: No edema.
550491 - ..
550492 - HEALTH STATUS: ASA [2].
550494 - ..
550495 - CONSENT: The procedure was discussed with the patient with the
550496 - benefits and risks, including but not limited to pain,
550497 - discomfort, oral trauma, medication reaction, bleeding,
550498 - infection, perforation, need for surgery, missed pathology,
550499 - cardiovascular/pulmonary compromise and others up to and
550500 - including death. All questions were answered. The patient was
550501 - aware of the risks and gave written informed consent.
550503 - ..
550504 - Saying "All questions were answered" is insufficient. Progress Notes
550505 - should list questions asked, and answers provided.
550507 - ..
550508 - EGD Progress Notes on 160617 continue...
550509 -
550510 - ENDOSCOPIST: Andrew Chao, MD (Fellow) and Randall Lee, MD
550511 - (Attending)
550513 - ..
550514 - 2. MEDICATIONS:
550515 -
550516 - 1. 6 milligrams versed IV
550517 - 2. 250 micrograms fentanyl IV
550518 - 3. 50 milligrams benadryl IV
550519 - 4. 5 mL 1% viscous lidocaine PO
550521 - ..
550522 - 3. Antibiotics: None
550523 -
550524 - Scope In: 0937
550525 - Scope Out: 1007
550527 - ..
550528 - This 30 minute procedure was twice as long as prior 15 minute
550529 - procedure on 160315.
550531 - ..
550532 - What occurred that took 100% longer?
550534 - ..
550535 - EGD Progress Notes on 160617 continue...
550536 -
550537 - 4. TIMEOUT WAS PERFORMED: name, medical record number and site
550538 - were confirmed.
550540 - ..
550541 - 5. DESCRIPTION OF PROCEDURE:
550542 -
550543 - 1. The patient was brought to the Endoscopy Suite and was
550544 - given 2 liters of supplemental oxygen by nasal cannula.
550545 - Cardiac and pulse oximetry monitoring were performed.
550546 -
550547 - 2. After adequate intravenous conscious sedation, a bite block
550548 - was inserted in the mouth.
550550 - ..
550551 - Bite block is placed while conscious.
550553 - ..
550554 - EGD Progress Notes on 160617 continue...
550555 -
550556 - 3. The Olympus 190 diagnostic endoscope was directly inserted
550557 - into the mouth and then esophagus, where a distal
550558 - esophageal ulcer was noted at the level of luminal
550559 - narrowing/stricture. Slight resistance was encountered,
550560 - but this was traversed and the endoscope advanced into the
550561 - stomach and to the proximal and descending duodenum.
550563 - ..
550564 - 4. Retroflexion of the endoscope in the stomach was performed
550565 - with visualization of the fundoplication.
550567 - ..
550568 - 5. Then after decompression of the duodenum and stomach, the
550569 - scope was withdrawn, while examining the mucosal surfaces.
550571 - ..
550572 - 6. The stricture was re-examined and a Boston Scientific
550573 - Esophageal Balloon Dilation Catheter was inserted and the
550574 - balloon was placed across the stricture with sequential
550575 - inflation from 12mm to 13.5mm to 15mm and then deflated
550576 - after visualization of mucosal tearing.
550578 - ..
550579 - Reporting "sequential inflation" from 12mm, seems conflicting with
550580 - post procedure report that LESV contracted to 9.5mm, per above.
550581 - ref SDS 0 5H5J
550583 - ..
550584 - Discharge document shows "Dilation 10 -> 15" which suggests the nurse
550585 - rounded 9.5 off to 10. Patient history shows LESV starting at 12
550586 - would have resulted in dilating LESV to 16mm or possibly 17mm;
550587 - whereas, dilating to 15 mm, as occurred today, correlates more closely
550588 - with patient history of LESV contracting to 9.5mm - 10mm. Therefore,
550589 - assume post procedure report of 9.5mm is accurate.
550591 - ..
550592 - EGD Progress Notes on 160617 continue...
550593 -
550594 - 7. The area was then injected with triamcinolone (40mg/mL;
550595 - total 5mL injected). The patient tolerated the procedure
550596 - well.
550598 - ..
550599 - Triamcinolone injection 5mL seems about 60% increase over 3mL
550600 - injection during prior procedure 3 months earlier on 160315 0900.
550601 - ref SDS G6 OJ47
550603 - ..
550604 - Patient later demonstrated stroke symptoms with loss of motor control
550605 - and vision, reported in another record today on 160617 1637.
550606 - ref SDS G8 5F6F
550608 - ..
550609 - Case study shows generally favorable history injecting
550610 - triamcinolone...
550611 -
550612 - LESV DILATE Triamcin Diphenhy Fenta Bena Midaz Lido
550613 - Months from - to olone Versed dramine nyl dryl olam caine
550614 - Interval Date mm mm mL mg mg mg mg mg mL
550615 - *1 3 160617 9.5 15......5.0.....6..............250.....50...............5...... ref SDS 0 HU42
550616 - *2 4 160315 9.5 15......3.0............25......250.............5........5...... ref SDS G6 HU42
550617 - 8 151204 10 15......5.0............25......200.............5........5...... ref SDS F3 HU42
550618 - 6 150421 16.5 18......3.0............50......250.............4........5...... ref SDS D3 HU42
550619 - 6 141107 15 18......4.0............50......150.............5........5...... ref SDS C4 E54M
550620 - 6 140509 16.5 18.....................50......200.............5........5...... ref SDS B4 P680
550621 - 7 131115 16.5 18......2.0............50......200.............4........5...... ref SDS A6 RZ45
550622 - 3 130416 18 18......2.0.....5..............250.....50...............5...... ref SDS A0 Y850
550623 - 4 130110 15 18......3.0............50......100.............4........5...... ref SDS 95 Q333
550624 - *3 6 120925 15 18......4.0............50......200.............5........5...... ref SDS 87 XB51
550625 - 4 120322 16.5 18.....................50......150.............4........5...... ref SDS 84 516N
550626 - 3 111115 16.5 18.....................50......200.............4........5...... ref SDS 82 IR57
550627 - 4 110819 15 16.5....2.5............50......200.............5........5...... ref SDS 81 J978
550628 - 3 110429 13 16.5....3.5.....5..............200.....50...............5...... ref SDS 76 U23I
550629 - 3 110218 11 14......2.0............50......150.............4........5...... ref SDS 72 AA5O
550630 - 4 101210 11 14......................................................5...... ref SDS 67 H347
550631 - 5 100827 11 15..............5..............250.....50...............5...... ref SDS 55 JE6X
550632 - 3 100305 11 15..............5..............250.....50...............5...... ref SDS 48 WR6L
550633 - 091216 Heller Myotomy Fundoplication....................................... ref SDS 36 KE9U
550635 - ..
550636 - Background on triamcinolone injection is further reviewed in the
550637 - record for the meeting at the VA on 140509 0900. ref SDS B4 R26H
550639 - ..
550640 - ** Notes
550641 -
550642 - *1 Lidocaine is entered as 5mL on 160617, ref SDS 0 P341 The
550643 - quantity is not entered on prior Progress Notes (could be
550644 - entered in Nurses Notes). This is not an exact measurement.
550645 - The nurse squirts Lidocaine into the mouth from a hand held
550646 - container, and asks patient to gargle for 30 seconds.
550647 -
550648 - *2 Triamcinolone injected on 160315 Progress Notes say
550649 - "about 3mL" indicating not exact measurement.
550650 - ref SDS G6 OJ47
550652 - ..
550653 - [On 160909 0800 Doctor Lee explained Triamcinolone is
550654 - injected at multiple sites around perimeter of LESV, and
550655 - with each injection there is spillage from overflow that
550656 - signals when to stop the injection, thus injection
550657 - quantities are qualified as "approximate." This suggests
550658 - each site may have greater or less Triamcinolone than an
550659 - adjacent site based on variable absorbtion rates of
550660 - surrounding material. ref SDS H4 5T6F
550661 -
550663 - ..
550664 - *3 Triamcinolone 4mL comprised 4 injections of 1mL into each of
550665 - 4 quatrants, reported on 120925 0900. ref SDS 87 N
550667 - ..
550668 - There is no other record specifying specific amounts of
550669 - Triamcinolone being injected into separate quadrants of LESV.
550671 - ..
550672 - Frequent references to "about" and "approximtely" indicate quantities
550673 - of Triamcinolone vary slightly up or down from measurements shown.
550674 - Quantity of Triamcinolone today on 160617, might have been closer to
550675 - 5.5mL and quantity on 151204, might have been 4.5ml, comprising 1mL
550676 - increase above prior highest amount of Triamcinolone that was
550677 - tolerated. Some authorities report Triamcinolone is distributed in
550678 - 5mL vials (seemingly, indicated by research...
550679 -
550680 - KENALOG®-40 INJECTION
550681 - (triamcinolone acetonide injectable suspension, USP)
550682 - NOT FOR USE IN NEONATES
550683 - CONTAINS BENZYL ALCOHOL
550684 -
550685 - http://packageinserts.bms.com/pi/pi_kenalog-40.pdf
550687 - ..
550688 - If injection syrenge is filled from 5mL container, then accuracy of
550689 - 5mL may be precise. This same source indicates administration of
550690 - Triamcinolone requires careful attention to detail. Further research
550691 - is needed for application to treating LESV in particular.
550693 - ..
550694 - Triamcinolone common dose for patient history is 2 - 3ml. ref SDS 0
550695 - LD8O
550697 - ..
550698 - It seems that 40 mg of Triamcinolone = 1 mL, so 5 mL vial contains
550699 - 200 mg.
550701 - ..
550702 - Research found...
550703 -
550704 - Drugs.com
550705 - Kenalog-40
550706 - Administration
550707 -
550708 - https://www.drugs.com/pro/kenalog-40.html#s9.2
550710 - ..
550711 - STRICT ASEPTIC TECHNIQUE IS MANDATORY. The vial should be
550712 - shaken before use to ensure a uniform suspension. Prior to
550713 - withdrawal, the suspension should be inspected for clumping or
550714 - granular appearance (agglomeration). An agglomerated product
550715 - results from exposure to freezing temperatures and should not
550716 - be used. After withdrawal, Kenalog-40 Injection should be
550717 - injected without delay to prevent settling in the syringe.
550718 - Careful technique should be employed to avoid the possibility
550719 - of entering a blood vessel or introducing infection.
550721 - ..
550722 - Are quality control methods of cross-checking manufacturers
550723 - instructions for use to verify check-list of steps is performed?
550725 - ..
550726 - How is technique verified to avoid entering blood vessel; might this
550727 - be a means of causing loss of vision loss and motor control in this
550728 - case?
550729 -
550731 - ..
550732 - Research - 1 source lists 1.5mL adult "systemic dosage" (see page 7)...
550733 -
550734 - PRESCRIBING INFORMATION
550735 - KENALOG*-40 INJECTION
550736 - (Triamcinolone Acetonide Injectable Suspension, U.S.P); 40 mg/mL
550737 -
550738 - http://www.bmscanada.ca/static/products/en/pil_pdf/KENALOG-40_EN_PIL.pdf
550740 - ..
550741 - By this criteria, 2 - 3mL indicates aggressive treatment to recover
550742 - from achalasia.
550743 -
550744 - [On 160909 0800 Doctor Lee explained Triamcinolone is
550745 - injected at multiple sites around perimeter of LESV, and
550746 - with each injection there is spillage from overflow that
550747 - signals when to stop the injection, thus injection
550748 - quantities are qualified as "approximate." This suggests
550749 - each site may have greater or less Triamcinolone than an
550750 - adjacent site based on variable absorbtion rates of
550751 - surrounding material. ref SDS H4 5T6F
550753 - ..
550754 - "Vision loss" has been reported by this source, but clarified as
550755 - "intravitreal administration" (into the eye), which does not apply
550756 - here; but, nothing in this case aligns perfectly with published
550757 - literature.
550759 - ..
550760 - Another source on administering Triamcinolone (Kenalog-40) lists side
550761 - effects include...
550762 -
550763 - RxList
550764 - Kenalog-40 Injection
550765 - Kenalog-40 Side Effects Center
550766 -
550767 - http://www.rxlist.com/kenalog-40-side-effects-drug-center.htm
550768 -
550769 - problems with your vision
550770 - dangerously high blood pressure
550771 - feeling short of breath with mild exertion
550772 - weight gain
550774 - ..
550775 - This authority does not associate "problems with vision" to solely
550776 - injection into the eyes, as the prior source could be interpreted to
550777 - indicate. ref SDS 0 UD6L
550778 -
550779 - [On 160823 0920 at 0924 Doctor Massa called and advised
550780 - that he spoke with Doctor Kim at Stanford Neuroscience and
550781 - they concurred there is no literature associating patient
550782 - stroke symptoms with EGD procedures. ref SDS H2 NG9J
550784 - ..
550785 - Triamcinolone possibly 5.5mL - 70% greater than typical dose - and in
550786 - combination with differences in sedation medications, i.e., Versed and
550787 - Benedryl, instead of Diphenhydramine and Midazolam, see above,
550788 - ref SDS 0 LD8O - may have tipped the patient into a reactive state
550789 - causing slight clinical stroke symptoms of motor control and vision
550790 - deficit following EGD procedure on 160617, ref SDS G8 5F6F, and found
550791 - the next day in MRI study on 160618. ref SDS G9 WK7K
550793 - ..
550794 - Since Triamcinolone <= 4 ml has been well tolerated, this may be a
550795 - guide for future upper limits in this case, along with consideration
550796 - for combinations with other medications.
550798 - ..
550799 - Triamcinolone 4.0 +/- has been tried twice in this case, after
550800 - significant contraction of LESV. The 1st attempt on 120925 shows no
550801 - evident improvement. The 2nd more recent use on 141107, shows
550802 - significant improvement, i.e., (50%) reduced LESV contraction,
550803 - yielding positive results in relation to risks of adverse neurology
550804 - outcome.
550806 - ..
550807 - Triamcinolone 5.0 +/- has been used twice. The 1st occurred on
550808 - 151204, after largest LESV contraction in patient history of 8 mm,
550809 - i.e., LESV contraction increased 500%, resulting from extending EGD
550810 - procedure from 6 months to 8 months, shows no evident effect, in that
550811 - 4 months later, LESV contracted back to 10 mm, the same as it was 4
550812 - months earlier. There is vague recollection that after this treatment
550813 - the patient did not feel quite normal, though without evident clinical
550814 - neurological symptoms of motor control and vision deficits, and did
550815 - not report adverse effects. The 2nd use of 5.0 +/- Triamcinolone
550816 - occurred today, 3 months after prior use of 3.0 mL, and despite
550817 - showing significant improvement with LESV contracting only 3 mm.
550818 - Patient history indicates this was significant progress toward
550819 - expanding LESV back to 18 mm baseline, and so nominally, would not
550820 - indicate necessity for administering higher risk 5mL Triamcinolone
550821 - treatment.
550823 - ..
550824 - There was, however, and understanding after the meeting on 160617,
550825 - that LESV actually contracted back to 9.5 mm, which conflicts with the
550826 - written report of contraction to 12 mm. ref SDS 0 HU42 The Discharge
550827 - document says "Dilation 10 -> 15", which aligns closer to 9.5 (often
550828 - rounded off to 10 in verbal communication among busy staff). LESV
550829 - contracting to 9.5 mm or even 10 mm would be the worst condition in
550830 - patient history, and thus a basis for trying more aggressive treatmet
550831 - with Triamcinolone to maintain LESV nearer to normal swallowing.
550833 - ..
550834 - Assuming Triamcinolone remains effective for up to 6 months, prior
550835 - injection 8 months earlier may have worn off, and so injecting 5mL on
550836 - 151204, caused no additive effects. Injecting 5mL Triamcinolon today,
550837 - on 160617, 3 months after prior 3 mL injection may have had additive
550838 - effects that caused neurology impariments.
550839 -
550840 - [On 160907 1420 letter notifies medical team that
550841 - Triamcinolone may have caused stroke symptoms on 160617,
550842 - because dose over 3 month period accumulated to
550843 - significantly more than commonly given in this case.
550844 - ref SDS H3 BI60
550846 - ..
550847 - Since 2 and 3mL treatments with Triamcinolon have been effective in
550848 - this case for 6 month treatmet cycles, this might continue to be a
550849 - guide for shorter cycles of < 4 months, thus avoiding additive effects
550850 - that correlate with adverse neurology affects.
550852 - ..
550853 - EGD Progress Notes on 160617 continue...
550854 -
550855 - 6. FINDINGS:
550856 -
550857 - 1. ESOPHAGUS:
550858 -
550859 - 1. Distal esophageal stricture from 38cm to 39cm, slight
550860 - resistance encountered, but then traversed and
550862 - ..
550863 - 2. dilated with through the scope balloon dilation (12mm
550864 - --> 13.5mm --> 15mm) with mucosal tearing visualized
550865 - and then injected with triamcinolone
550867 - ..
550868 - See analysis above on LESV contracting to 9.5 mm. ref SDS 0 3Y4G
550870 - ..
550871 - EGD Progress Notes on 160617 continue...
550872 -
550873 - 3. Hemi-circumferential distal esophageal ulceration at
550874 - the level of the stricture
550876 - ..
550877 - This seems to reverse impression from prior procedure of "... no
550878 - longer any associated erosive esophagitis and there is no evidence of
550879 - mass effect. This implies better acid suppression compared to the
550880 - previous examination of December 2015. The patient's symptoms of
550881 - breakthrough for which he has been using sodium bicarbonate does
550882 - indicate an area for improvement," reported on 160315 0900.
550883 - ref SDS G6 PXXY
550885 - ..
550886 - Aligns with reduced protection with fundoplication "relaxed", per
550887 - prior findings on 160315 0900. ref SDS G6 7Q71 Increased ulceration
550888 - on LESV further aligns with ending Baking Soda, and reducing
550889 - Omeprazole to 20 mg every other day, discussed after the procedure on
550890 - 160315 0900. ref SDS G6 RZ3G
550892 - ..
550893 - Adding Famotidine did not replace acid protection of relaxed
550894 - fundoplication nor reducing Omperazole to 20 mg every other day, and
550895 - ending Baking Soda.
550897 - ..
550898 - EGD Progress Notes on 160617 continue...
550899 -
550900 - 4. Dilated esophagus proximal to stricture with mucosal
550901 - changes consistent with stasis
550903 - ..
550904 - 5. Hiatal Hernia from 39cm to 41cm
550905 -
550907 - ..
550908 - 2. STOMACH:
550909 -
550910 - 1. Mild peri-pyloric erythema, otherwise unremarkable
550911 -
550912 - 2. Gastric fundus with appearance of anatomical alteration
550913 - consistent with prior hisotry of fundoplication,
550914 - relaxed
550916 - ..
550917 - 3. DUODENUM: Unremarkable
550919 - ..
550920 - 4. EBL: Zero
550921 -
550923 - ..
550924 - 7. IMPRESSION:
550925 -
550926 - 1. Distal esophageal stricture from 38cm to 39cm, slight
550927 - resistance encountered, but then traversed and
550928 -
550929 - 2. dilated with through the scope balloon dilation (12mm -->
550930 - 13.5mm --> 15mm) with mucosal tearing visualized and then
550931 -
550932 - 3. injected with triamcinolone
550934 - ..
550935 - 4. Hemi-circumferential distal esophageal ulceration at the
550936 - level of the stricture; this was not present at last
550937 - endoscopy and implied suboptimal acid- suppression in the
550938 - context of QOD PPI (twice daily H2B)
550940 - ..
550941 - Aligns with post-procedure discussion Doctor Lee reporting increased
550942 - ulceration LESV, per above. ref SDS 0 RZ3G
550944 - ..
550945 - Severe "impression" of ulceration aligns with findings, per above,
550946 - ref SDS 0 194N; and, reverses prior favorable impression that
550947 - ulceration was completely resolved on prior regimen of Baking Soda and
550948 - Omeprazole 20 mg every other day, reported in Progress Notes for pior
550949 - procedure on 160315 0900. ref SDS G6 PXXY
550951 - ..
550952 - EGD Progress Notes on 160617 continue...
550953 -
550954 - 8. RECOMMENDATIONS:
550955 -
550956 - 1. recommend increase in acid-suppressive therapy with PPI
550957 - (from QOD to at least daily/BID if patient agreeable)
550959 - ..
550960 - After the meeting today, Doctor Lee prescribed increasing Famotidine
550961 - 20 mg 1 time per day combined with Omperazole 20 mg every other day,
550962 - to taking Famotidine 40 mg twice per day, see above. ref SDS 0 Q05K
550964 - ..
550965 - EGD Progress Notes on 160617 continue...
550966 -
550967 - 2. repeat EGD with likely dilation in 3 mo
550968 -
550969 - [On 160816 0800 next EGD dilation was performed 3 weeks
550970 - in advance of schedule on 160909, ordered by Doctor Lee
550971 - today. ref SDS H1 NU8L
550972 -
550973 - /es/ Andrew Chao, MD
550974 - Gastroenterology & Hepatology Fellow, PGY-4
550975 - Signed: 06/17/2016 10:27
550976 -
550977 - /es/ Randall E. Lee, MD
550978 - Staff Physician, Gastroenterology
550979 - Cosigned: 07/15/2016 08:52
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550982 -
550983 -
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550991 -
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550993 -