CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 35 0000. ref SDS 33 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Meeting today, scheduled by Doctor Lee during prior EGD procedure on
040902 - 160909 0800. ref SDS 33 4U5F
040904 - ..
040905 - Several days ago, met with GI Clinic at VAMCSF for 2nd opinion on work
040906 - in progress to consider stent options and causes for stroke symptoms
040907 - following EGD on 160617, set out in the record on 160919 0830.
040908 - ref SDS 35 PA8L
040910 - ..
040911 - Agenda tracked issues discussed during meeting with (Joe) Giuseppe
040912 - Cullaro at VAMCSF on 160919 0830. ref SDS 35 PA8L
040913 -
040914 -
040915 - 1. Review patient history performing procedures to resolve
040916 - achalasia...
040918 - ..
040919 - Clarify multiple names for conscious sedation medicaitons
040920 - listed Progress Notes and shown in concentration case study...
040922 - ..
040923 - Details listed on 160909 0800. ref SDS 33 KJ5N
040925 - ..
040926 - LESV DILATE Triamcin Diphenhy Fenta Bena Midaz Lido
040927 - Months from - to olone Versed dramine nyl dryl olam caine
040928 - Interval Date mm mm mL mg mg mg mg mg mL
040929 - 0.75 160909 10 15......5.0.....3 ??...........250.....50...............5...... ref SDS 33 HU42
040930 - 2 160816 9.5 10......5.0.....6..............250.....50...............5...... ref SDS 29 HU42
040931 - 3 160617 9.5 15......5.0.....6..............250.....50...............5...... ref SDS 21 HU42
040932 - 4 160315 9.5 15......3.0............25......250.............5........5...... ref SDS 20 HU42
040933 - 8 151204 10 15......5.0............25......200.............5........5...... ref SDS 19 HU42
040934 - 6 150421 16.5 18......3.0............50......250.............4........5...... ref SDS 18 HU42
040935 - 6 141107 15 18......4.0............50......150.............5........5...... ref SDS 16 E54M
040936 - 6 140509 16.5 18.....................50......200.............5........5...... ref SDS 15 P680
040937 - 7 131115 16.5 18......2.0............50......200.............4........5...... ref SDS 13 RZ45
040938 - 3 130416 18 18......2.0.....5..............250.....50...............5...... ref SDS 12 Y850
040939 - 4 130110 15 18......3.0............50......100.............4........5...... ref SDS 11 Q333
040940 - 6 120925 15 18......4.0............50......200.............5........5...... ref SDS 10 XB51
040941 - 4 120322 16.5 18.....................50......150.............4........5...... ref SDS 9 516N
040942 - 3 111115 16.5 18.....................50......200.............4........5...... ref SDS 8 IR57
040943 - 4 110819 15 16.5....2.5............50......200.............5........5...... ref SDS 7 J978
040944 - 3 110429 13 16.5....3.5.....5..............200.....50...............5...... ref SDS 6 U23I
040945 - 3 110218 11 14......2.0............50......150.............4........5...... ref SDS 5 AA5O
040946 - 4 101210 11 14......................................................5...... ref SDS 4 H347
040947 - 5 100827 11 15..............5..............250.....50...............5...... ref SDS 3 JE6X
040948 - 3 100305 11 15..............5..............250.....50...............5...... ref SDS 2 WR6L
040949 - 091216 Heller Myotomy Fundoplication....................................... ref SDS 1 KE9U
040951 - ..
040952 - Doctor Lee took hand written notes on paper from the study above, for
040953 - Progress Notes on correlations of medications, including Triamcinolone
040954 - in relation to frequency of procedures, showing rate of concentration
040955 - buildup.
040957 - ..
040958 - The doctor explained multiple names for sedation medications are
040959 - actually the same things; this changes medication concentration study
040960 - to show...
040961 -
040962 -
040963 - Bena
040964 - Versed/ dryl
040965 - LESV DILATE Triamcin Midaz Diphenhy Fenta Lido
040966 - Months from - to olone olam dramine nyl caine
040967 - Interval Date mm mm mL mg mg mg mL
040968 - 0.75 160909 10 15......5.0.....5......25......200......5.... ref SDS 33 HU42
040969 - 2 160816 9.5 10......5.0.....4......50......150......5.... ref SDS 29 HU42
040970 - 3 160617 9.5 15......5.0.....6......50......250......5.... ref SDS 21 HU42
040971 - 4 160315 9.5 15......3.0.....5......25......250......5.... ref SDS 20 HU42
040972 - 8 151204 10 15......5.0.....5......25......200......5.... ref SDS 19 HU42
040973 - 6 150421 16.5 18......3.0.....4......50......250......5.... ref SDS 18 HU42
040974 - 6 141107 15 18......4.0.....5......50......150......5.... ref SDS 16 E54M
040975 - 6 140509 16.5 18..............5......50......200......5.... ref SDS 15 P680
040976 - 7 131115 16.5 18......2.0.....4......50......200......5.... ref SDS 13 RZ45
040977 - 3 130416 18 18......2.0.....5......50......250......5.... ref SDS 12 Y850
040978 - 4 130110 15 18......3.0.....4......50......100......5.... ref SDS 11 Q333
040979 - 6 120925 15 18......4.0.....5......50......200......5.... ref SDS 10 XB51
040980 - 4 120322 16.5 18..............4......50......150......5.... ref SDS 9 516N
040981 - 3 111115 16.5 18..............4......50......200......5.... ref SDS 8 IR57
040982 - 4 110819 15 16.5....2.5.....5......50......200......5.... ref SDS 7 J978
040983 - 3 110429 13 16.5....3.5.....5..............200......5.... ref SDS 6 U23I
040984 - 3 110218 11 14......2.0.....4......50......150......5.... ref SDS 5 AA5O
040985 - 4 101210 11 14......................................5.... ref SDS 4 H347
040986 - 5 100827 11 15..............5......50......250......5.... ref SDS 3 JE6X
040987 - 3 100305 11 15..............5......50......250......5.... ref SDS 2 WR6L
040988 - 091216 Heller Myotomy Fundoplication..................... ref SDS 1 KE9U
040989 -
040990 -
040992 - ..
040993 - 2. Triamcinolone overdose
040994 -
040995 - Published guidance on overdose?
040997 - ..
040998 - Overdose side effects, reviewed on 160617 0800. ref SDS 21 PG6I
040999 -
041000 - 1. Vison loss......................................... 160617, ref SDS 22 5F6F
041001 - High blood pressure beginning 160622............... 140101 0600, ref SDS 14 WXXS
041002 - Weight gain beginning........ 160622
041003 - bloating beginning........... 160622
041005 - ..
041006 - Doctor Lee seemed to say today, there is published guidance on
041007 - administering Triamcinolone to avoid overdose. He explained there is
041008 - less risk when injecting Triamcinolone to a specific body part, as in
041009 - this case LESV, rather than for systemic injections in the hip, or a
041010 - joint.
041012 - ..
041013 - Asked the doctor to submit sources that guide injection dose into LESV
041014 - in order to monitor "overdose side effects" suffered the past 3
041015 - months, per above. ref SDS 0 II4G
041017 - ..
041018 - Discussed balance risks and benefits increasing Triamcinolone dose
041019 - above 3 mL?
041021 - ..
041022 - Doctor Lee seemed to say today, that he injects Triamcinolone into
041023 - locations where there is split tissue caused by dilations and he may
041024 - have possibly said ulceration.
041026 - ..
041027 - Since there was no dilation for the procedure on 160816, does
041028 - injecting 5 mL indicate there remained 5 splits from the prior
041029 - dilation procedure on 160617, 2 months earlier? Was lingering split
041030 - tissue the result of increased ulceration?
041032 - ..
041033 - Need clarification on performing all injections from the top LESV,
041034 - because that is the initial entry of the dilating instrument? Are
041035 - steriod injections ever performed from the stomach side of LESV?
041037 - ..
041038 - What happens to spillage of Triamcinolone, reported on 160909 0800.
041039 - ref SDS 33 5T6F Is it suctioned out, or allowed to seep into the
041040 - system, with possible increased risk of overdose, per above.
041041 - ref SDS 0 EX9I
041042 -
041043 -
041045 - ..
041046 - 3. Stroke symptoms and 2nd Opinion Stanford Neuroscience
041048 - ..
041049 - Doctor Lee said Peer Review report on what caused stroke symptoms
041050 - following EGD procedure on 160617, was scheduled to be discussed this
041051 - morning at a doctors conference. The doctor assigned to perform the
041052 - Peer Review had to treat a patient in the Emergency Room (ER) at the
041053 - time the conference met, and so the report was not delivered. Doctor
041054 - Lee later talked to the Chief of the GI Clinic, who assigned the
041055 - doctor for performing the Peer Review, and requested release of the
041056 - report.
041058 - ..
041059 - Asked if the Chief could join our meeting to report on status?
041061 - ..
041062 - Doctor Lee said the Chief has not seen the report, and so could not
041063 - explain findings and recommendations.
041064 -
041065 - [On 161004 0800 during meeting prior to EGD dilation
041066 - procedure, Doctor Lee reported he has still not seen Peer
041067 - Review report on what caused stroke symptoms following
041068 - procedure in 160617. ref SDS 37 UE5H
041070 - ..
041071 - Doctor Lee said he has not seen 2nd opinion letter received from
041072 - Stanford Neuroscience. It is dated 160802, the same day as the
041073 - meeting with Doctor Vora and Doctor Kim on 160802 1300. ref SDS 28
041074 - VN9K However, Stanford's letter was received in the US mail on 160820
041075 - 0940. ref SDS 30 R66J
041077 - ..
041078 - Today, hand carried the copy of the letter addressed to Doctor Massa.
041079 - Doctor Lee left the room for a few minutes to make a copy of this
041080 - letter from his files. On returning to the office, Doctor Lee read
041081 - the letter dated 160802, issued by Doctor Kim and Doctor Vora, and
041082 - addressed to Doctor Massa. ref SDS 30 R66J
041083 -
041084 - [On 161003 0628 letter notifies medical team at VA Medical
041085 - Center in San Francisco that Doctor Lee read the 2nd
041086 - opinion letter dated 160802, issued by Stanford
041087 - Neuroscience. ref SDS 36 WR72
041089 - ..
041090 - After reading through 2nd Opinion letter dated 160802, issued by
041091 - Stanford Neuroscience, ref SDS 30 R66J, Doctor Lee noted the letter
041092 - is addressed to Doctor Massa with...
041093 -
041094 - cc: Doctor Randall Lee.
041096 - ..
041097 - Doctor Lee said again today during the meeting, that he did not make
041098 - the referral to Stanford Neuroscience, presented previously on 160816
041099 - 0800. ref SDS 29 7Z5N
041101 - ..
041102 - Explained again, that Stanford Neuroscience showed a document during
041103 - the meeting at Stanford on 160802, which seemed to list the VA doctor
041104 - making the referral as...
041105 -
041106 - Doctor Randall M Lee
041108 - ..
041109 - Doctor Lee said his middle initial is E, and there are multiple
041110 - doctors at the VA with the name Randall Lee. He used the VA computer
041111 - in the office to access VA staffing. He found several doctors with
041112 - the name Randall Lee assigned to UCSF Medical Center at the Parnassus
041113 - campus in San Francisco.
041114 -
041115 - Doctor Randall J Lee
041116 - Doctor Randall P Lee
041118 - ..
041119 - Did not find Doctor Randall M Lee, which was listed in the Stanford
041120 - Neuroscience document as the referring doctor in this case.
041122 - ..
041123 - Possibly, Doctor Massa asked one of them to sign the approval for
041124 - Stanford Neuroscience to perform 2nd opinion work, and possibly there
041125 - was a typographical error entering the name in the Stanford
041126 - Neuroscience form.
041128 - ..
041129 - During the meeting today, Doctor Lee commented that the Stanford 2nd
041130 - opinion dated 160802, is helpful and necessary for correcting
041131 - erroneous diagnosis of stroke in this case, and suggesting anethesia
041132 - in the procedure on 160617, may have caused stroke symptoms following
041133 - the procedure, and reported in MRI findings the next day on 160618
041134 - 1348, ref SDS 23 IY8H, as further set out in Stanford's 2nd opinion
041135 - received on 160820 0940, ref SDS 30 JF86, where no stroke actually
041136 - occurred. He said if there is any difficulty getting the VA to pay
041137 - for the work, that he would make sure the patient recovers the payment
041138 - of $855, originally paid on 160802 1300. ref SDS 28 9I7O
041139 -
041140 -
041142 - ..
041143 - 4. Current work plan
041144 -
041145 - Perform EGD dilation on 161004 0800, hope LESV does not
041146 - contract back to 10 mm, and in that case attempt to expand LESV
041147 - to 18 mm once again, for first time since 150421.
041149 - ..
041150 - Resolution ulceration LESV, having switched to Pentoprazole on
041151 - 160816, ref SDS 29 Q05K, and recommended by Debbie on 160722
041152 - 1335, ref SDS 26 3K32, and adding Baking Soda approved by
041153 - Doctor Lee on 160909 0800. ref SDS 33 Q05K
041154 -
041156 - ..
041157 - 5. Patient Status
041158 -
041159 - 1. No vomiting since exigent EGD without dilation on 160816,
041160 - and after switching to Pentoprazole, and despite no
041161 - dilation on 160816, and dilating from 10 - 15 mm on 160909.
041162 -
041163 - Best performance in 9 months - very good.
041165 - ..
041166 - This has continued, no vomiting since EGD dilation on
041167 - 160909.
041168 -
041170 - ..
041171 - 2. Paused Pentoprazole on 160911, to reduce side effects
041172 - frequent urination, and in order to hike Half Dome, which
041173 - requires elevated hydration.
041175 - ..
041176 - What other medication ideas can reduce acid reflux with
041177 - less side effects.
041178 -
041180 - ..
041181 - 3. Hiked Half Dome on 160914.
041183 - ..
041184 - Doctor Lee liked Half Dome pictures, and again related having hiked
041185 - Half Dome 30 years ago. Originally, thought he did this with his
041186 - wife, but he clarified today it was with a friend, i.e., 2 guys.
041188 - ..
041189 - He asked how the knees held up, and illustrated how he suffered knee
041190 - sorenss the day after his hike, and emphasized this was primarily
041191 - assoicated with coming down the mountain, rather the hike up.
041193 - ..
041194 - Doctor Lee discussed the prospects of doing a less rigorous hike next
041195 - year, which he could join.
041197 - ..
041198 - Explained the guide for the hike last week on 160914, Lindsey, said
041199 - she does mellow hikes. We could ask her for ideas.
041201 - ..
041202 - Doctor Lee likes outdoors activities, shown by his recent vacation to
041203 - Death Valley.
041205 - ..
041206 - He also mentioned hiking to the top of Mount Whitney, as an
041207 - alternative. He thinks we could drive to a point 4 miles or so from
041208 - the top, and hike up.
041209 -
041210 -
041212 - ..
041213 - 4. Baking Soda increased treat increased stomach upset,
041214 - seeming withdrawal from Pantoprazole.
041216 - ..
041217 - Doctor Lee drew a diagram to explain how withdrawal symptoms of
041218 - stomach pain and bloating occur from stopping Pantoprazole 40 mg twice
041219 - per day all at once.
041220 -
041221 -
041222 - 1. PPI Pantoprazole suppresses production of stomach acid.
041224 - ..
041225 - 2. When the stomach has no acid, it reacts by increasing
041226 - production of "gastin."
041228 - ..
041229 - 3. Gastin stimulates the body to produce more acid in order to
041230 - resolve the deficit caused by PPI.
041232 - ..
041233 - 4. When PPI is stopped abruptly, the stomach continues to produce
041234 - elevated levels of gastin for about 2 weeks, even though there
041235 - is more acid in the stomach than needed for digesting food.
041237 - ..
041238 - 5. Elevated gastin increases stomach above the level required to
041239 - digest food, because PPI has been stopped.
041241 - ..
041242 - 6. This excess acid causes stomach pain and bloating for about 2
041243 - weeks until body adjusts and begins producing less gastin.
041245 - ..
041246 - 7. Antacid remedies like Baking Soda, Tums and other treatments
041247 - can resolve excess acid until amount of acid is redued below a
041248 - noticable threshold.
041250 - ..
041251 - 8. H2 Blocker like Famotidine can further reduce production of
041252 - excess acid, but in only 1 of 3 or 4 production points in
041253 - stomach cells that produce acid.
041254 -
041255 -
041256 -
041258 - ..
041259 - 5. Baking Soda decreased as withdrawal symptoms subsided,
041260 - beginning on 160918.
041262 - ..
041263 - However, past 2 days this problem has increased requiring
041264 - increased Baking Soda.
041266 - ..
041267 - Doctor Lee prescribed a new regimen today in order to reduce severe
041268 - withdrawl symptoms from PPI Pantoprazole, to improve control of acid
041269 - production for the purpose of maintaining improvement of ulceration
041270 - found in the procedure on 160909, and to decrease frequency of
041271 - urination.
041272 -
041273 - 1. PPI Pentoprazole 40 mg resume, but only 1 time per day about 30
041274 - minutes before eating evening meal, rather than twice per day.
041276 - ..
041277 - 2. Famotidine 40 mg resume, but only 1 time per day in the
041278 - morning, and not required with food.
041280 - ..
041281 - 3. Anticid of choice (e.g., Tums or Baking Soda), taken before
041282 - going to sleep at night.
041284 - ..
041285 - This will prevent acid being produced over night causing
041286 - increased ulceration from pooling acid on LESV, that flows up
041287 - from the stomach easier when laying down, especially on the
041288 - back.
041289 -
041290 -
041292 - ..
041293 - 6. Appetite declined - eating only few bites few meals since
041294 - 160914.
041296 - ..
041297 - Doctor Lee seemed to say this occurred from stopping PPI on 160817.
041298 - The body reduces appetite in order to reduce stimulous for producing
041299 - increased acid, per above. ref SDS 0 ZZ7L
041300 -
041301 -
041302 -
041304 - ..
041305 - 7. Weight dropped 10 - 15 pounds past 10 days.
041306 -
041308 - ..
041309 - 4. Swallowing esophagus options
041310 -
041311 - 1. Continue EGD dilation on demonstration of progress
041312 - following EGD dilation on 161004.
041314 - ..
041315 - 2. Stricture and ulceration
041316 -
041317 - Please draw diagram showing these separate afflictions,
041318 - and explain what causes each.
041320 - ..
041321 - Photographs showing advanced ulceration and that is now
041322 - resolved, and that stricture remains.
041324 - ..
041325 - What causes stricture?
041327 - ..
041328 - Doctor Lee explained "stricture" is merely a narrowing of esophagus.
041329 - There is no evident change to the tissue. It occurs from same process
041330 - of increased stomach acid that causes ulceration.
041332 - ..
041333 - This seems to indicate that reducing ulceration by reducing stomach
041334 - acid will resolve the stricture.
041335 -
041337 - ..
041338 - 3. Stent
041340 - ..
041341 - Doctor Stewart recommended against stent, reported on 160823 1430.
041342 - ref SDS 31 UL4H
041344 - ..
041345 - Similarly, Doctor Cullaro (Fellow) said GI Department at VAMCSF feels
041346 - patient status does not justify consideration of stent solution.
041347 -
041349 - ..
041350 - 4. Surgery re-do Heller Myotomy fundoplication
041352 - ..
041353 - We reviewed the record of continuing EGD dilation procedures finding
041354 - Dor fundoplication constructed on 091216, has been failing, reported
041355 - on 150319 0800, ref SDS 17 KN6F
041357 - ..
041358 - Doctor Stewart continues to rely on hoped for improvement with EGD
041359 - dilations.
041360 - ..
041362 - ..
041363 - 5. Endoscope fundoplication, reported in research on 160911
041364 - 0908. ref SDS 34 L544
041366 - ..
041367 - This would avoid surgery, if fundoplication can be repaired
041368 - with Gastroscope???
041370 - ..
041371 - Doctor Lee seemed to agree that repairing fundoplication in this case
041372 - would reduce the continuing problem of balancing high levels of PPI,
041373 - H2 Blocker, and antacid required in this case to avoid ulceration and
041374 - prevent stricture, but also prevent frequent urination that causes
041375 - dehydration, which injures feet and prevents hiking required to
041376 - prevent recurrence of atherosclerosis.
041378 - ..
041379 - Doctor Lee said that using the gastroscope to repair fundoplication
041380 - requires additional training, which he does have.
041382 - ..
041383 - The doctor will research the matter. He would not be comfortable
041384 - experimenting with referral, unless he can find a doctor who has a
041385 - great many of these procedures using the endoscope to perform
041386 - fundoplication. He mention 500, but a doctor who has done 300 might
041387 - worth having a meeting to discuss the prospects.
041389 - ..
041390 - He would then make a referral for consultation to consider if the
041391 - patient fits the profile that would enable using the endoscope to
041392 - repair failed Dor fundoplication.
041394 - ..
041395 - He might go with the patient to meet with the prospective doctor for
041396 - gastroscope fundoplication.
041398 - ..
041399 - If the referral doctor reports that Dor fundoplication repair has a
041400 - good chance of success, then Doctor Lee could assist in a procedure on
041401 - another patient in order to decide on making a referral in this case,
041402 - based on recognizing comparable conditions resulted in successful Dor
041403 - fundoplication repair.
041405 - ..
041406 - Doctor Lee would consult with the patient and report his opinion on
041407 - chances of success.
041409 - ..
041410 - If the patient concurs, the doctor would make a referral.
041412 - ..
041413 - Doctor Lee could assist in the procedure to repair Dor fundoplication
041414 - using gastroscope.
041416 - ..
041417 - If this is successful, could make further referrals on other patients
041418 - as needed.
041419 -
041420 -
041422 - ..
041423 - 6. Dilation with a single large (16?20 mm) dilator leads to
041424 - rupture of the Schatzki ring and symptomatic relief in
041425 - almost all patients, reported in research on 160911 0908,
041426 - ref SDS 34 Y86J
041427 -
041428 -
041429 -
041430 -
041431 -
0415 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Download Medical Records from VA Internet Server
050403 -
050404 - Follow up ref SDS 33 CY7I, ref SDS 29 CY7I,.
050406 - ..
050407 - Request records on CD from ROI for this medical encounter due to
050408 - continual difficulties downloading medical records from VA website
050409 - at...
050410 -
050411 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
050413 - ..
050414 - Customer....
050415 -
050416 - User ID..................... rodwelch
050417 - Password.................... Poims&7cm
050419 - ..
050420 - On September 7, 2016, checked for Progress Notes for EGD on 160617,
050421 - and found they have not yet been posted for patient access.
050422 -
050424 - ..
050425 - Downloaded Progess Notes for procedure on 160617, and stored in...
050426 -
050427 - F:\05\00003\SM\CC\AGMJ\20160921-113000\mhv_WELCH_20161004_0855.txt
050429 - ..
050430 - This file includes numerous reports flowing from EGD Dilation
050431 - procedure on 160617; there is no particular order for the records in
050432 - this file.
050433 -
050435 - ..
050436 - Progress Notes Meeting on 160921 for Review EGD Dilation on 160909
050437 -
050438 - Follow up ref SDS 33 9N5G, ref SDS 29 9N5G.
050439 -
050440 -
050441 - Date/Time: 21 Sep 2016 @ 1130
050442 - Note Title: Gastroenterology Attending F/U Note 60127
050443 - Location: No CA Healthcare Sys-Martinez
050444 - Signed By: LEE,RANDALL E
050445 - Co-signed By: LEE,RANDALL E
050446 - Date/Time Signed: 21 Sep 2016 @ 1445
050447 - -------------------------------------------------------------------------
050449 - ..
050450 - LOCAL TITLE: Gastroenterology Attending F/U Note 60127
050451 - STANDARD TITLE: GASTROENTEROLOGY ATTENDING NOTE
050452 - DATE OF NOTE: SEP 21, 2016@11:30 ENTRY DATE: SEP 21, 2016@14:44:36
050453 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
050454 - URGENCY: STATUS: COMPLETED
050455 -
050456 - 1677242
050457 - >60 minutes
050459 - ..
050460 - For some reason, Doctor Lee has not entered the record for this
050461 - meeting, per agenda above. ref SDS 0 PA8L
050462 -
050463 -
050464 - /es/ Randall E. Lee, MD
050465 - Staff Physician, Gastroenterology
050466 - Signed: 09/21/2016 14:45
050467 -
050468 -
050469 -
050470 -
050471 -
050472 -
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050474 -
050475 -
050476 -
050477 -
050478 -
050479 -
050480 -
050481 -
050482 -
050483 -
050484 -
050485 -
050486 -
050487 -
050488 -
050489 -
050490 -